Provider Demographics
NPI:1922012343
Name:BRECK SLEEP LAB, INC
Entity type:Organization
Organization Name:BRECK SLEEP LAB, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JILL
Authorized Official - Middle Name:L
Authorized Official - Last Name:KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:CRT
Authorized Official - Phone:254-559-2023
Mailing Address - Street 1:203 S GENEVA ST
Mailing Address - Street 2:
Mailing Address - City:BRECKENRIDGE
Mailing Address - State:TX
Mailing Address - Zip Code:76424-4701
Mailing Address - Country:US
Mailing Address - Phone:254-559-2023
Mailing Address - Fax:254-559-9770
Practice Address - Street 1:203 S GENEVA ST
Practice Address - Street 2:
Practice Address - City:BRECKENRIDGE
Practice Address - State:TX
Practice Address - Zip Code:76424-4701
Practice Address - Country:US
Practice Address - Phone:254-559-2023
Practice Address - Fax:254-559-9770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPL7191OtherBLUE CROSS BLUE SHIELD
TXPL7191OtherBLUE CROSS BLUE SHIELD