Provider Demographics
NPI:1982114872
Name:BROWN, BEAU (ATC, LAT)
Entity type:Individual
Prefix:
First Name:BEAU
Middle Name:
Last Name:BROWN
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9604 VINCA CIR APT A
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-0002
Mailing Address - Country:US
Mailing Address - Phone:910-265-4563
Mailing Address - Fax:
Practice Address - Street 1:640 SUMMIT CROSSING PL STE 208
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2142
Practice Address - Country:US
Practice Address - Phone:704-671-5750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25532255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer