Provider Demographics
NPI:1710461090
Name:MEDFORD, BEVERLY JEAN
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:JEAN
Last Name:MEDFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9318 E PICKARD RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-9463
Mailing Address - Country:US
Mailing Address - Phone:989-772-7588
Mailing Address - Fax:
Practice Address - Street 1:9318 E. PICKARD RD.
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT MI
Practice Address - State:MI
Practice Address - Zip Code:48858
Practice Address - Country:US
Practice Address - Phone:989-772-7588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-21
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF370393943311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home