Healthcare Provider Details

I. General information

NPI: 1649102005
Provider Name (Legal Business Name): KAITLYN BEACH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1049 ROQUEMORE DR
ORANGEBURG SC
29115-8936
US

IV. Provider business mailing address

50 THUNDER CIR
SANTEE SC
29142-9440
US

V. Phone/Fax

Practice location:
  • Phone: 803-216-5150
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: