MEDICARE: NINA R BECKWELL MT

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	204C00000X	Sports Medicine (Neuromusculoskeletal Medicine) Physician	MASH-2190	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0	OTHER		UNKNOWN
2	0	OTHER		NA

General Provider Information

NPI Number	:	1447773023
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NINA R BECKWELL MT

Provider Business Mailing Address
First Line	:	1432 HIGHWAY 13
Second Line	:
City	:	GRANGEVILLE
State	:	ID
Zip	:	83530-5006
Country	:	US
Telephone Number	:	630-605-9616
Fax Number	:

Provider Business Practice Location Address
First Line	:	321 W MAIN ST
Second Line	:
City	:	GRANGEVILLE
State	:	ID
Zip	:	83530-1917
Country	:	US
Telephone Number	:	630-605-9616
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2017
Last Update Date	:	07/25/2017

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Directions to “ NINA R BECKWELL MT” Practice Location

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