Provider Demographics
NPI:1255519492
Name:BEACH, JAN WESLEY (LMT)
Entity type:Individual
Prefix:MR
First Name:JAN
Middle Name:WESLEY
Last Name:BEACH
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4800 N FEDERAL HWY
Mailing Address - Street 2:301E
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-5188
Mailing Address - Country:US
Mailing Address - Phone:561-809-4985
Mailing Address - Fax:
Practice Address - Street 1:4800 N FEDERAL HWY
Practice Address - Street 2:301E
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-5188
Practice Address - Country:US
Practice Address - Phone:561-809-4985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-08
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA45714225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist