Provider Demographics
NPI:1558358184
Name:BEAVER MEDICAL, LLC
Entity type:Organization
Organization Name:BEAVER MEDICAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-438-7280
Mailing Address - Street 1:PO BOX 1690
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:UT
Mailing Address - Zip Code:84713-1690
Mailing Address - Country:US
Mailing Address - Phone:435-438-7280
Mailing Address - Fax:435-438-7210
Practice Address - Street 1:450 EAST CLINIC WAY
Practice Address - Street 2:
Practice Address - City:PAROWAN
Practice Address - State:UT
Practice Address - Zip Code:84761-1690
Practice Address - Country:US
Practice Address - Phone:435-477-3344
Practice Address - Fax:435-477-3475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CG2421OtherRAILROAD MEDICARE
UT000055384Medicare PIN
UT463820Medicare Oscar/Certification