Provider Demographics
NPI:1336106889
Name:BEAVERS, TYRA L
Entity Type:Individual
Prefix:
First Name:TYRA
Middle Name:L
Last Name:BEAVERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TYRA
Other - Middle Name:
Other - Last Name:DOUGLAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 N ROBERTSON BLVD STE 411
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-1793
Mailing Address - Country:US
Mailing Address - Phone:310-859-7696
Mailing Address - Fax:310-859-7699
Practice Address - Street 1:250 N ROBERTSON BLVD
Practice Address - Street 2:SUITE 516
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1788
Practice Address - Country:US
Practice Address - Phone:310-859-7696
Practice Address - Fax:310-859-7699
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23792111N00000X
CADC23792111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC23792OtherPRIVATE INSURANCE
CA200355585OtherPRIVATE INS TAX ID
CA200355585OtherPRIVATE INS TAX ID
CAW17119Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
CAU67766Medicare UPIN