Healthcare Provider Details

I. General information

NPI: 1558175745
Provider Name (Legal Business Name): BEVERLY CARLISLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2025
Last Update Date: 02/06/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6016 GEORGETOWN DR APT 73
COLUMBUS GA
31907-4664
US

IV. Provider business mailing address

6016 GEORGETOWN DR
COLUMBUS GA
31907-4697
US

V. Phone/Fax

Practice location:
  • Phone: 706-315-0685
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number0028837239
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: