Healthcare Provider Details

I. General information

NPI: 1770570202
Provider Name (Legal Business Name): BEAVER MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 11/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1059 N 100 W
BEAVER UT
84713-1690
US

IV. Provider business mailing address

PO BOX 1690
BEAVER UT
84713-1690
US

V. Phone/Fax

Practice location:
  • Phone: 435-438-7280
  • Fax: 435-438-7210
Mailing address:
  • Phone: 435-438-7280
  • Fax: 435-438-7210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number47255720160
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. JULIE CHRISTENSEN
Title or Position: OFFICE MANAGER
Credential:
Phone: 435-438-7280