Basic Information
| Provider Information | |||||||||
| NPI: | 1245486844 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEARDSLEY | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CPO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BEARDSLEY | ||||||||
| OtherFirstName: | CHRISTOPHER | ||||||||
| OtherMiddleName: | P | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CPO | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3700 BRAINERD RD | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374113603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236970057 | ||||||||
| FaxNumber: | 4236489366 | ||||||||
| Practice Location | |||||||||
| Address1: | 3700 BRAINERD RD | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374113603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236970057 | ||||||||
| FaxNumber: | 4236489366 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2008 | ||||||||
| LastUpdateDate: | 09/07/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | Other Service Providers | Specialist |
No ID Information.