Provider Demographics
NPI:1336733278
Name:BEASLEY, KEINYA S
Entity type:Individual
Prefix:
First Name:KEINYA
Middle Name:S
Last Name:BEASLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6845 FIVE STAR BLVD STE E
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-2686
Mailing Address - Country:US
Mailing Address - Phone:916-308-2442
Mailing Address - Fax:
Practice Address - Street 1:6845 FIVE STAR BLVD STE E
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-2686
Practice Address - Country:US
Practice Address - Phone:916-308-2442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-22
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA337138332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment