Organization
SOUTH CENTRAL REGIONAL SLEEP LAB
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JOHN M. WALLACE M.D. (DIRECTOR)
(601) 426-4530
Entity
Organization
Contact information
Practice address
1220 JEFFERSON ST, LAUREL, MS 39440-4355
(601) 426-4530
Mailing address
PO BOX 6511, LAUREL, MS 39441-6511
(601) 426-4530
Taxonomy
Speciality
Code
Description
License number
State
293D00000X
Physiological Laboratory
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
09557052
—
MS
Enumeration date
08/12/2006
Last updated
08/22/2020
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