Provider Demographics
NPI:1154665644
Name:BEACHSIDE CLINIC INC
Entity Type:Organization
Organization Name:BEACHSIDE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:C
Authorized Official - Last Name:HORNICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:842-877-5224
Mailing Address - Street 1:931 MEDICAL CIR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4122
Mailing Address - Country:US
Mailing Address - Phone:843-877-5224
Mailing Address - Fax:
Practice Address - Street 1:931 MEDICAL CIR
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4122
Practice Address - Country:US
Practice Address - Phone:843-877-5224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-21
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier