Provider Demographics
NPI:1639497233
Name:BEACH CHIROPRACTIC ARTS CENTER PC
Entity Type:Organization
Organization Name:BEACH CHIROPRACTIC ARTS CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/D.C.
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:R
Authorized Official - Last Name:BEACH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:402-721-1190
Mailing Address - Street 1:1835 E MILITARY AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:NE
Mailing Address - Zip Code:68025-5477
Mailing Address - Country:US
Mailing Address - Phone:402-721-1190
Mailing Address - Fax:
Practice Address - Street 1:1835 E MILITARY AVE
Practice Address - Street 2:STE 107
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-5477
Practice Address - Country:US
Practice Address - Phone:402-721-1190
Practice Address - Fax:402-721-1199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-07
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE690111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE091493Medicare PIN