Provider Demographics
NPI:1417344433
Name:SOUTHEN TRANQUILITY MEDISPA, INC.
Entity Type:Organization
Organization Name:SOUTHEN TRANQUILITY MEDISPA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CARLTON
Authorized Official - Middle Name:REID
Authorized Official - Last Name:BEAMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:PA-C
Authorized Official - Phone:252-308-0686
Mailing Address - Street 1:130 CARDINAL DR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870
Mailing Address - Country:US
Mailing Address - Phone:252-365-4440
Mailing Address - Fax:252-308-0862
Practice Address - Street 1:130 CARDINAL DR
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-4946
Practice Address - Country:US
Practice Address - Phone:252-365-4440
Practice Address - Fax:252-308-0862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-16
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101911261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center