MEDICARE: J BEVERLY ENTERPRISES, 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	261QC1500X	Community Health Clinic/Center

General Provider Information

NPI Number	:	1134993058
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	J BEVERLY ENTERPRISES, LLC

Provider Business Mailing Address
First Line	:	2329 RODNEY CT
Second Line	:
City	:	SPRINGFIELD
State	:	OR
Zip	:	97477-1964
Country	:	US
Telephone Number	:	805-440-8341
Fax Number	:

Provider Business Practice Location Address
First Line	:	1110 18TH ST STE 6
Second Line	:
City	:	SPRINGFIELD
State	:	OR
Zip	:	97477-4200
Country	:	US
Telephone Number	:	541-517-3970
Fax Number	:	458-201-8188

Authorized Official
Title or Position	:	OWNER
Name	:	JAMIE BEVERLY
Credential	:
Telephone Number	:	541-517-3970

Provider Enumeration Date	:	11/10/2023
Last Update Date	:	11/10/2023

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