Healthcare Provider Details

I. General information

NPI: 1861228892
Provider Name (Legal Business Name): ALEX BEAUDREAULT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2024
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 S OAKHURST DR APT 103
BEVERLY HILLS CA
90212-3552
US

IV. Provider business mailing address

129 S OAKHURST DR APT 103
BEVERLY HILLS CA
90212-3552
US

V. Phone/Fax

Practice location:
  • Phone: 860-230-8499
  • Fax:
Mailing address:
  • Phone: 860-230-8499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: