Provider Demographics
NPI:1700485505
Name:BEAUCHAMP, TYLER (PTA, ATC)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:BEAUCHAMP
Suffix:
Gender:M
Credentials:PTA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 NORTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52806-1861
Mailing Address - Country:US
Mailing Address - Phone:563-449-7004
Mailing Address - Fax:
Practice Address - Street 1:6101 NORTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52806-1861
Practice Address - Country:US
Practice Address - Phone:563-449-7004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA105325225200000X
IA0803422255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant