Provider Demographics
NPI:1841220811
Name:CGR BEACON CLINIC, PA
Entity Type:Organization
Organization Name:CGR BEACON CLINIC, PA
Other - Org Name:CGR BEACON CLINIC, PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ARNP
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:JOAN
Authorized Official - Last Name:ROSENFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:941-629-7855
Mailing Address - Street 1:PO BOX 496080
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33949-6080
Mailing Address - Country:US
Mailing Address - Phone:941-629-7855
Mailing Address - Fax:941-629-9589
Practice Address - Street 1:3782 TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-8353
Practice Address - Country:US
Practice Address - Phone:941-629-7855
Practice Address - Fax:941-629-9589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2935382101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ0119Medicare ID - Type Unspecified