=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306873310
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSEPH STEVEN BEACH PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12138 S MAIN ST
-----------------------------------------------------
City | TRENTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30752-5151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-657-2700
-----------------------------------------------------
Fax | 706-657-7965
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 942
-----------------------------------------------------
City | TRENTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30752-0942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-657-2700
-----------------------------------------------------
Fax | 706-657-7965
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | PTA0000000881
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | PTA000430
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------