Provider Demographics
NPI:1710101118
Name:BECKETT, DAVID C (PT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:C
Last Name:BECKETT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5797 JAMAIL DR NE
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49306-8867
Mailing Address - Country:US
Mailing Address - Phone:616-245-3795
Mailing Address - Fax:
Practice Address - Street 1:3282 CLEAR VISTA CT NE
Practice Address - Street 2:SUITE A
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9477
Practice Address - Country:US
Practice Address - Phone:616-365-2709
Practice Address - Fax:616-365-3174
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010865225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN41100004Medicare ID - Type UnspecifiedPROVIDER NUMBER