MEDICARE: BROKEN ARROW PEDIATRIC BEHAVIORAL HEALTH LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080P0006X	Developmental - Behavioral Pediatrics Physician

General Provider Information

NPI Number	:	1083231724
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROKEN ARROW PEDIATRIC BEHAVIORAL HEALTH LLC

Provider Business Mailing Address
First Line	:	502 W ATLANTA ST
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-7004
Country	:	US
Telephone Number	:	918-752-4403
Fax Number	:

Provider Business Practice Location Address
First Line	:	502 W ATLANTA ST
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-7004
Country	:	US
Telephone Number	:	918-752-4403
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. BILLY C BEETS
Credential	:	MD
Telephone Number	:	918-752-4403

Provider Enumeration Date	:	06/29/2020
Last Update Date	:	06/29/2020

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