Provider Demographics
NPI:1013009083
Name:BEACH, MARY LOU (DC, CCSP)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:LOU
Last Name:BEACH
Suffix:
Gender:F
Credentials:DC, CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 E FRONT ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-5309
Mailing Address - Country:US
Mailing Address - Phone:309-828-3415
Mailing Address - Fax:309-828-2665
Practice Address - Street 1:409 E FRONT ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-5309
Practice Address - Country:US
Practice Address - Phone:309-828-3415
Practice Address - Fax:309-828-2665
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-005425111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT38488Medicare UPIN
ILL61561Medicare ID - Type Unspecified