Basic Information
| Provider Information | |||||||||
| NPI: | 1437212172 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RICH | ||||||||
| FirstName: | BEVEN | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | ATC, MT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14222 W COEUR DALENE DR | ||||||||
| Address2: | |||||||||
| City: | SPIRIT LAKE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838698732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086236272 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1172 W HAYDEN AVE | ||||||||
| Address2: | |||||||||
| City: | HAYDEN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838358700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087623332 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | AT-217 | ID | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 225700000X | X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.