Healthcare Provider Details

I. General information

NPI: 1720576366
Provider Name (Legal Business Name): STEPHEN A BEALL LDO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2018
Last Update Date: 04/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 N ASHLEY ST
VALDOSTA GA
31602-1709
US

IV. Provider business mailing address

3001 N ASHLEY ST
VALDOSTA GA
31602-1709
US

V. Phone/Fax

Practice location:
  • Phone: 229-247-8484
  • Fax:
Mailing address:
  • Phone: 229-247-8484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberLDO000598
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: