Provider Demographics
NPI:1720332828
Name:BEATTY, EDWARD EARL JR
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:EARL
Last Name:BEATTY
Suffix:JR
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 1:720 INDIANA AVE APT D
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-3312
Mailing Address - Country:US
Mailing Address - Phone:740-856-8238
Mailing Address - Fax:
Practice Address - Street 1:1000 LINCOLN DR
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-2304
Practice Address - Country:US
Practice Address - Phone:304-768-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001811225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant