Healthcare Provider Details

I. General information

NPI: 1417344433
Provider Name (Legal Business Name): SOUTHEN TRANQUILITY MEDISPA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2015
Last Update Date: 04/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 CARDINAL DR
ROANOKE RAPIDS NC
27870-4946
US

IV. Provider business mailing address

130 CARDINAL DR
ROANOKE RAPIDS NC
27870
US

V. Phone/Fax

Practice location:
  • Phone: 252-365-4440
  • Fax: 252-308-0862
Mailing address:
  • Phone: 252-365-4440
  • Fax: 252-308-0862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number101911
License Number StateNC

VIII. Authorized Official

Name: MR. CARLTON REID BEAMAN JR.
Title or Position: MEDICAL DIRECTOR/OWNER
Credential: PA-C
Phone: 252-308-0686