Provider Demographics
NPI:1114929619
Name:BEAVERS, JEFFERY G (DC)
Entity Type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:G
Last Name:BEAVERS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5707 MARCONI AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-4471
Mailing Address - Country:US
Mailing Address - Phone:916-489-5450
Mailing Address - Fax:
Practice Address - Street 1:5707 MARCONI AVE
Practice Address - Street 2:SUITE D
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-4471
Practice Address - Country:US
Practice Address - Phone:916-489-5450
Practice Address - Fax:916-489-2175
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC0170060111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT06327Medicare UPIN