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NPI Code Detail

MEDICARE: SOUTHEN TRANQUILITY MEDISPA, INC.

MEDICARE: SOUTHEN TRANQUILITY MEDISPA, INC.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261Q00000XClinic/Center101911NC

General Provider Information

NPI Number : 1417344433
Entity Type Code : Organization
Provider Name (Legal Business Name) : SOUTHEN TRANQUILITY MEDISPA, INC.
Provider Business Mailing Address
First Line : 130 CARDINAL DR
Second Line :
City : ROANOKE RAPIDS
State : NC
Zip : 27870
Country : US
Telephone Number : 252-365-4440
Fax Number : 252-308-0862
Provider Business Practice Location Address
First Line : 130 CARDINAL DR
Second Line :
City : ROANOKE RAPIDS
State : NC
Zip : 27870-4946
Country : US
Telephone Number : 252-365-4440
Fax Number : 252-308-0862
Authorized Official
Title or Position : MEDICAL DIRECTOR/OWNER
Name : MR. CARLTON REID BEAMAN JR.
Credential : PA-C
Telephone Number : 252-308-0686
Provider Enumeration Date : 04/16/2015
Last Update Date : 04/16/2015

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Directions to “SOUTHEN TRANQUILITY MEDISPA, INC. ” Practice Location

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