Provider Demographics
NPI:1518291731
Name:BECKLEY, CHADRICK GORDON (BC-HIS)
Entity Type:Individual
Prefix:MR
First Name:CHADRICK
Middle Name:GORDON
Last Name:BECKLEY
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1850 IDAHO ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2575
Mailing Address - Country:US
Mailing Address - Phone:208-746-6068
Mailing Address - Fax:208-743-2025
Practice Address - Street 1:1850 IDAHO ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2575
Practice Address - Country:US
Practice Address - Phone:208-746-6068
Practice Address - Fax:208-743-2025
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-21
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDHA-1062237700000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist