Healthcare Provider Details

I. General information

NPI: 1316964406
Provider Name (Legal Business Name): CARL BEAL JR. ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 01/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 WYOMING BLVD NE
ALBUQUERQUE NM
87109-3843
US

IV. Provider business mailing address

6400 WYOMING BLVD NE
ALBUQUERQUE NM
87109-3843
US

V. Phone/Fax

Practice location:
  • Phone: 505-828-3181
  • Fax:
Mailing address:
  • Phone: 505-828-3181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number288
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: