1710949094 NPI number — MR. WAYNE ALAN BECK III MSH, ATC, CHES

Table of content: MR. WAYNE ALAN BECK III MSH, ATC, CHES (NPI 1710949094)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710949094 NPI number — MR. WAYNE ALAN BECK III MSH, ATC, CHES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BECK
Provider First Name:
WAYNE
Provider Middle Name:
ALAN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
III
Provider Credential Text:
MSH, ATC, CHES
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1710949094
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
121 B 13TH AVE., S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32250
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-476-1226
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3536 PHILLIPS HWY
Provider Second Line Business Practice Location Address:
BUILDING A, SUITE 106
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32207-5612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-202-5806
Provider Business Practice Location Address Fax Number:
904-202-5587
Provider Enumeration Date:
04/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  AL 1684 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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