Provider Demographics
NPI:1043670011
Name:BEACHEM, PAUL BRYAN IV (ATC)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:BRYAN
Last Name:BEACHEM
Suffix:IV
Gender:M
Credentials:ATC
Other - Prefix:
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Mailing Address - Street 1:7400 OLD MAIN HILL
Mailing Address - Street 2:DALE MILDENBERGER SPORTS MEDICINE COMPLEX
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84322
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7400 OLD MAIN HILL
Practice Address - Street 2:DALE MILDENBERGER SPORTS MEDICINE COMPLEX
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84322
Practice Address - Country:US
Practice Address - Phone:435-797-3636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9067793-48102255A2300X
PARTO0001892255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer