Provider Demographics
NPI:1922579341
Name:BEAGUE, NATITA
Entity Type:Individual
Prefix:
First Name:NATITA
Middle Name:
Last Name:BEAGUE
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 1:12941 ROYAL GEORGE AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-5710
Mailing Address - Country:US
Mailing Address - Phone:727-408-4666
Mailing Address - Fax:
Practice Address - Street 1:12941 ROYAL GEORGE AVE
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:FL
Practice Address - Zip Code:33556-5710
Practice Address - Country:US
Practice Address - Phone:727-408-4666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-11
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL733200Medicaid