Provider Demographics
NPI:1730285453
Name:PHETSINORATH, BE (DC)
Entity Type:Individual
Prefix:
First Name:BE
Middle Name:
Last Name:PHETSINORATH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3263 DEMETROPOLIS RD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36693-4638
Mailing Address - Country:US
Mailing Address - Phone:251-665-4999
Mailing Address - Fax:251-665-4998
Practice Address - Street 1:3263 DEMETROPOLIS RD
Practice Address - Street 2:SUITE 10
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36693-4638
Practice Address - Country:US
Practice Address - Phone:251-665-4999
Practice Address - Fax:251-665-4998
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2156111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL83642Medicare UPIN