Healthcare Provider Details

I. General information

NPI: 1023700499
Provider Name (Legal Business Name): BEAU URBANIAK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2023
Last Update Date: 05/24/2023
Certification Date: 05/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7421 W VICTORY RD STE 103
BOISE ID
83709-6764
US

IV. Provider business mailing address

7201 W CLEARWATER AVE STE B101
KENNEWICK WA
99336-1694
US

V. Phone/Fax

Practice location:
  • Phone: 208-514-3736
  • Fax: 208-514-3672
Mailing address:
  • Phone: 509-544-0265
  • Fax: 509-987-1614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT8650
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: