Provider Demographics
NPI:1497713127
Name:BEAM, VINCENT LEE (AT,C)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:LEE
Last Name:BEAM
Suffix:
Gender:M
Credentials:AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1480 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-2010
Mailing Address - Country:US
Mailing Address - Phone:417-256-5669
Mailing Address - Fax:417-256-5699
Practice Address - Street 1:1480 W 8TH ST
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-2010
Practice Address - Country:US
Practice Address - Phone:417-256-5669
Practice Address - Fax:417-256-5699
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1070412255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO107041OtherATHLETIC TRAINER