Basic Information
| Provider Information | |||||||||
| NPI: | 1912003716 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEASON | ||||||||
| FirstName: | MIRANDA | ||||||||
| MiddleName: | KATE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 616 | ||||||||
| Address2: | |||||||||
| City: | PONCHA SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812420616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195302293 | ||||||||
| FaxNumber: | 7195302232 | ||||||||
| Practice Location | |||||||||
| Address1: | 448 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | SALIDA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 812012804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195302293 | ||||||||
| FaxNumber: | 7195302232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 04/23/2010 | ||||||||
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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 | 133V00000X | 00934419 | NE | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.