Healthcare Provider Details

I. General information

NPI: 1770787335
Provider Name (Legal Business Name): BEACH CLINIC INC P S
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 12/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N. MONTESANO
WESTPORT WA
98595
US

IV. Provider business mailing address

801 N MONTESANO PO BOX 2229
WESTPORT WA
98595
US

V. Phone/Fax

Practice location:
  • Phone: 360-268-0195
  • Fax: 360-268-1442
Mailing address:
  • Phone: 360-268-0195
  • Fax: 360-268-1442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOP00001807
License Number StateWA

VIII. Authorized Official

Name: SHELLY J DUEBER
Title or Position: PHYSICIAN
Credential: D.O.
Phone: 360-268-0195