Provider Demographics
NPI:1992163166
Name:BEESE, MARK ERIC (ATC, LAT)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ERIC
Last Name:BEESE
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 1:580 WAKARA WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108
Mailing Address - Country:US
Mailing Address - Phone:801-587-1473
Mailing Address - Fax:801-587-7115
Practice Address - Street 1:590 S WAKARA WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1200
Practice Address - Country:US
Practice Address - Phone:801-587-1473
Practice Address - Fax:801-587-7115
Is Sole Proprietor?:No
Enumeration Date:2016-02-03
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7726414-4810174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist