Provider Demographics
NPI:1922282904
Name:BEAVER, FREDRICK DAVID
Entity Type:Individual
Prefix:
First Name:FREDRICK
Middle Name:DAVID
Last Name:BEAVER
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:PO BOX 272
Mailing Address - Street 2:
Mailing Address - City:DRAGOON
Mailing Address - State:AZ
Mailing Address - Zip Code:85609-0272
Mailing Address - Country:US
Mailing Address - Phone:520-253-0352
Mailing Address - Fax:
Practice Address - Street 1:2750 N. NINO PLACE
Practice Address - Street 2:
Practice Address - City:COCHISE
Practice Address - State:AZ
Practice Address - Zip Code:85606
Practice Address - Country:US
Practice Address - Phone:520-253-0352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-26
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child