=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821291584
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEACH HEALTH CLINIC,INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3396 HOLLAND RD STE 102
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23452-4824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-428-5601
-----------------------------------------------------
Fax | 757-428-7872
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3396 HOLLAND RD STE 102
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23452-4824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-428-5601
-----------------------------------------------------
Fax | 757-428-7872
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MRS. SUSAN HELLSTROM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-428-5601
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 0201004157
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------