Healthcare Provider Details

I. General information

NPI: 1003017195
Provider Name (Legal Business Name): LYNETTE R. BEADLES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 08/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16981 PLACER HILLS RD B-7
MEADOW VISTA CA
95722
US

IV. Provider business mailing address

16981 PLACER HILLS RD B-7
MEADOW VISTA CA
95722
US

V. Phone/Fax

Practice location:
  • Phone: 530-878-8129
  • Fax: 530-878-8195
Mailing address:
  • Phone: 530-878-8129
  • Fax: 530-878-8195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number89503
License Number StateCA

VIII. Authorized Official

Name: MS. LYNETTE RAE BEADLES
Title or Position: OWNER OPERATOR
Credential:
Phone: 530-878-8129