Basic Information
| Provider Information | |||||||||
| NPI: | 1447430376 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CREATIVE LIFESTYLES MANAGEMENT PROG | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LABORATORY FOR SLEEP DISORDERS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7503 SURRATTS ROAD | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207353358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018707001 | ||||||||
| FaxNumber: | 3018706697 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 ST. PATRICKS DRIVE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | WALDORF | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206033500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018774600 | ||||||||
| FaxNumber: | 3018705747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2007 | ||||||||
| LastUpdateDate: | 11/10/2011 | ||||||||
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| AuthorizedOfficialLastName: | STEWART | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3018774541 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RS0012X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine |
No ID Information.