Provider Demographics
NPI:1760545719
Name:BEDDALL, WARREN GEOFFREY
Entity Type:Individual
Prefix:MR
First Name:WARREN
Middle Name:GEOFFREY
Last Name:BEDDALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 E SUNSET CT
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85365-3517
Mailing Address - Country:US
Mailing Address - Phone:928-344-4516
Mailing Address - Fax:
Practice Address - Street 1:1404 E SUNSET CT
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85365-3517
Practice Address - Country:US
Practice Address - Phone:928-344-4516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10808385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ991267Medicaid