Provider Demographics
NPI:1790410017
Name:BEARDEN, MICHAEL P
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
Last Name:BEARDEN
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 1:2525 CAMINO DEL RIO S STE 313
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3784
Mailing Address - Country:US
Mailing Address - Phone:619-823-6736
Mailing Address - Fax:
Practice Address - Street 1:2525 CAMINO DEL RIO S STE 313
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3784
Practice Address - Country:US
Practice Address - Phone:619-823-6736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-20
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA98365171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach