Healthcare Provider Details

I. General information

NPI: 1518291731
Provider Name (Legal Business Name): CHADRICK GORDON BECKLEY BC-HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2009
Last Update Date: 02/14/2022
Certification Date: 02/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 IDAHO ST
LEWISTON ID
83501-2575
US

IV. Provider business mailing address

1850 IDAHO ST
LEWISTON ID
83501-2575
US

V. Phone/Fax

Practice location:
  • Phone: 208-746-6068
  • Fax: 208-743-2025
Mailing address:
  • Phone: 208-746-6068
  • Fax: 208-743-2025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberHA-1062
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHA-1062
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: