Healthcare Provider Details

I. General information

NPI: 1710949094
Provider Name (Legal Business Name): WAYNE ALAN BECK III MSH, ATC, CHES
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3536 PHILLIPS HWY BUILDING A, SUITE 106
JACKSONVILLE FL
32207-5612
US

IV. Provider business mailing address

121 B 13TH AVE., S
JACKSONVILLE BEACH FL
32250
US

V. Phone/Fax

Practice location:
  • Phone: 904-202-5806
  • Fax: 904-202-5587
Mailing address:
  • Phone: 904-476-1226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL 1684
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: