1336136969 NPI number — BEAVER MEDICAL, LLC

Table of content: (NPI 1336136969)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336136969 NPI number — BEAVER MEDICAL, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BEAVER MEDICAL, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336136969
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1690
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAVER
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84713-1690
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-438-7280
Provider Business Mailing Address Fax Number:
435-438-7210

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
850 N MAIN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILFORD
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84751-0640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-387-2471
Provider Business Practice Location Address Fax Number:
435-387-2475
Provider Enumeration Date:
09/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CHRISTENSEN
Authorized Official First Name:
JULIE
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
435-438-7280

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: CG2421 . This is a "RAILROAD MEDICARE PALMETTO" identifier . This identifiers is of the category "OTHER".




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