Healthcare Provider Details

I. General information

NPI: 1194315424
Provider Name (Legal Business Name): ENDIA TALYNNE BEAVERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2021
Last Update Date: 01/20/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22851 LEXINGTON AVE
EASTPOINTE MI
48021-1990
US

IV. Provider business mailing address

11094 NOTTINGHAM RD
DETROIT MI
48224-1746
US

V. Phone/Fax

Practice location:
  • Phone: 586-218-8570
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: