Provider Demographics
NPI:1770787335
Name:BEACH CLINIC INC P S
Entity type:Organization
Organization Name:BEACH CLINIC INC P S
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:DUEBER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:360-268-0195
Mailing Address - Street 1:801 N MONTESANO
Mailing Address - Street 2:PO BOX 2229
Mailing Address - City:WESTPORT
Mailing Address - State:WA
Mailing Address - Zip Code:98595
Mailing Address - Country:US
Mailing Address - Phone:360-268-0195
Mailing Address - Fax:360-268-1442
Practice Address - Street 1:801 N. MONTESANO
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:WA
Practice Address - Zip Code:98595
Practice Address - Country:US
Practice Address - Phone:360-268-0195
Practice Address - Fax:360-268-1442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001807207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7103187Medicaid
WA7102221Medicaid
WA7103187Medicaid
WAH44463Medicare UPIN
WAGAB17158Medicare ID - Type UnspecifiedNONRURAL