Provider Demographics
NPI:1528561362
Name:BEACON BIOMEDICAL INC.
Entity Type:Organization
Organization Name:BEACON BIOMEDICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:GRIMES
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:480-757-9037
Mailing Address - Street 1:275 N GATEWAY DR STE 149
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85034-1700
Mailing Address - Country:US
Mailing Address - Phone:480-757-9037
Mailing Address - Fax:
Practice Address - Street 1:275 N GATEWAY DR STE 149
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85034-1700
Practice Address - Country:US
Practice Address - Phone:480-757-9037
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-16
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ03D2122615291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory