Provider Demographics
NPI:1992459697
Name:BEACH ECLINIC LLC
Entity type:Organization
Organization Name:BEACH ECLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ERIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:757-828-6188
Mailing Address - Street 1:3419 VIRGINIA BEACH BLVD # 436
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-4419
Mailing Address - Country:US
Mailing Address - Phone:757-828-6188
Mailing Address - Fax:888-588-5587
Practice Address - Street 1:413 22ND ST APT A
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-3389
Practice Address - Country:US
Practice Address - Phone:757-828-6188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No251E00000XAgenciesHome Health