Provider Demographics
NPI:1629497458
Name:BEASLEY, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:BEASLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21360 N 1450 E
Mailing Address - Street 2:PO BOX 461
Mailing Address - City:MORONI
Mailing Address - State:UT
Mailing Address - Zip Code:84646
Mailing Address - Country:US
Mailing Address - Phone:435-445-5200
Mailing Address - Fax:435-445-5201
Practice Address - Street 1:21360 N 1450 E
Practice Address - Street 2:
Practice Address - City:MORONI
Practice Address - State:UT
Practice Address - Zip Code:84646
Practice Address - Country:US
Practice Address - Phone:435-445-5200
Practice Address - Fax:435-445-5201
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-09
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility