Provider Demographics
NPI:1134320732
Name:SKIPPER, BEVERLY JO (REGISTERED DISPENSIN)
Entity type:Individual
Prefix:MS
First Name:BEVERLY
Middle Name:JO
Last Name:SKIPPER
Suffix:
Gender:F
Credentials:REGISTERED DISPENSIN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 HARBOUR WAY
Mailing Address - Street 2:SUITE 2
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94801
Mailing Address - Country:US
Mailing Address - Phone:510-232-7074
Mailing Address - Fax:510-232-7089
Practice Address - Street 1:322 HARBOUR WAY
Practice Address - Street 2:SUITE 2
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94801
Practice Address - Country:US
Practice Address - Phone:510-232-7074
Practice Address - Fax:510-232-7089
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADX004228FMedicaid