Provider Demographics
NPI:1760448617
Name:CARABACAN, BEETHOVEN (LAT, CSCS, BS, MS)
Entity Type:Individual
Prefix:MR
First Name:BEETHOVEN
Middle Name:
Last Name:CARABACAN
Suffix:
Gender:M
Credentials:LAT, CSCS, BS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 N 116TH ST
Mailing Address - Street 2:APT. 3
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3262
Mailing Address - Country:US
Mailing Address - Phone:414-324-4172
Mailing Address - Fax:
Practice Address - Street 1:1111 DELAFIELD ST
Practice Address - Street 2:SUITE 15
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3417
Practice Address - Country:US
Practice Address - Phone:262-521-9762
Practice Address - Fax:262-521-1091
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI657-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer