Provider Demographics
NPI:1033727953
Name:BEAMER, KENNETH ROBERT
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ROBERT
Last Name:BEAMER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12125 LAKE BLVD SPC 51
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96003-0781
Mailing Address - Country:US
Mailing Address - Phone:208-659-7818
Mailing Address - Fax:
Practice Address - Street 1:351 HARTNELL AVE
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-1845
Practice Address - Country:US
Practice Address - Phone:530-226-7651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95161840163WG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0100XNursing Service ProvidersRegistered NurseGastroenterology