Healthcare Provider Details

I. General information

NPI: 1790807485
Provider Name (Legal Business Name): ELIZABETH BECKHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

4720 LOWE RD
LOUISVILLE KY
40220-1552
US

IV. Provider business mailing address

4720 LOWE RD
LOUISVILLE KY
40220-1552
US

V. Phone/Fax

Practice location:
  • Phone: 502-459-2020
  • Fax: 502-456-9121
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberKY-0355
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: