Healthcare Provider Details

I. General information

NPI: 1912986787
Provider Name (Legal Business Name): STACY LYNN BEACH A.T.C
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 RT. 36
ROARING SPRING PA
16673
US

IV. Provider business mailing address

930 CHESTNUT ST
ROARING SPRING PA
16673-2012
US

V. Phone/Fax

Practice location:
  • Phone: 814-224-1371
  • Fax:
Mailing address:
  • Phone: 814-224-4634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT003520
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: