Healthcare Provider Details

I. General information

NPI: 1508408881
Provider Name (Legal Business Name): JIMMIE TYLER BEIRNE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2019
Last Update Date: 10/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4011 FEELY LN
ONA WV
25545-9762
US

IV. Provider business mailing address

4011 FEELY LN
ONA WV
25545-9762
US

V. Phone/Fax

Practice location:
  • Phone: 304-633-3882
  • Fax:
Mailing address:
  • Phone: 304-633-3882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT003667
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: