Provider Demographics
NPI:1629101936
Name:BEACH, KEN (PT)
Entity Type:Individual
Prefix:
First Name:KEN
Middle Name:
Last Name:BEACH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6811 TAYLOR RANCH DR NW
Mailing Address - Street 2:LB JOHNSON MS
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120
Mailing Address - Country:US
Mailing Address - Phone:505-898-1492
Mailing Address - Fax:
Practice Address - Street 1:6811 TAYLOR RANCH DR NW
Practice Address - Street 2:LB JOHNSON MS
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120
Practice Address - Country:US
Practice Address - Phone:505-898-1492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2150225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMQ 7135Medicaid