=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669803888
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC BEALER ATC/L
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2013
-----------------------------------------------------
Last Update Date | 04/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3700 S ARIZONA AVE
-----------------------------------------------------
City | CHANDLER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85248-4500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-883-5209
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1727 W FRYE RD
-----------------------------------------------------
City | CHANDLER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85224-5295
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 807-285-3931
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 1172
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------