Provider Demographics
NPI:1588828826
Name:KELLY S. BEALS, INC.
Entity Type:Organization
Organization Name:KELLY S. BEALS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIETITIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:S
Authorized Official - Last Name:BEALS
Authorized Official - Suffix:
Authorized Official - Credentials:RD/LD
Authorized Official - Phone:405-795-8535
Mailing Address - Street 1:3220 ROCKHAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73179-1223
Mailing Address - Country:US
Mailing Address - Phone:405-795-8535
Mailing Address - Fax:
Practice Address - Street 1:3220 ROCKHAMPTON AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73179-1223
Practice Address - Country:US
Practice Address - Phone:405-795-8535
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1076133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200089850AMedicaid
OK1013017003OtherINDIVIDUAL NPI (PRIOR TO FORMING CORPORATION)
OK863540OtherREGISTERED DIETITIAN
OK1076OtherLICENSED DIETITIAN