Healthcare Provider Details

I. General information

NPI: 1801821384
Provider Name (Legal Business Name): CODI BECKMAN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 FLAG DR
RIVERTON WY
82501-2312
US

IV. Provider business mailing address

PO BOX 2020
RIVERTON WY
82501-0274
US

V. Phone/Fax

Practice location:
  • Phone: 307-857-7074
  • Fax: 307-857-1072
Mailing address:
  • Phone: 307-857-7074
  • Fax: 307-857-1072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA - 455
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: