Healthcare Provider Details

I. General information

NPI: 1114204252
Provider Name (Legal Business Name): CHRISTOPHER WILLIAM BEATTY OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2011
Last Update Date: 11/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1817 ROSE ST
BERKELEY CA
94703-1117
US

IV. Provider business mailing address

1817 ROSE ST
BERKELEY CA
94703-1117
US

V. Phone/Fax

Practice location:
  • Phone: 411-960-2723
  • Fax:
Mailing address:
  • Phone: 411-960-2723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberOT 12019
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: