Provider Demographics
NPI:1679342919
Name:BEAUREGARD, MATTHEW J (ATC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:BEAUREGARD
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5931 N 125TH AVE
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340-3815
Mailing Address - Country:US
Mailing Address - Phone:216-633-2183
Mailing Address - Fax:
Practice Address - Street 1:2601 S WOOD BLVD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-6914
Practice Address - Country:US
Practice Address - Phone:623-302-5684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-28
Last Update Date:2023-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10182255A2300X
OHAT0035912255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer