Provider Demographics
NPI:1073713533
Name:BEAVERCREEK CHIROPRACTIC CLINIC INC
Entity Type:Organization
Organization Name:BEAVERCREEK CHIROPRACTIC CLINIC INC
Other - Org Name:BEAVERCREEK CHIROPRACTIC CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:P
Authorized Official - Last Name:PALKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:937-426-9265
Mailing Address - Street 1:1654 MARDON DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45432-1949
Mailing Address - Country:US
Mailing Address - Phone:937-426-9265
Mailing Address - Fax:937-426-9613
Practice Address - Street 1:1654 MARDON DR
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45432-1949
Practice Address - Country:US
Practice Address - Phone:937-426-9265
Practice Address - Fax:937-426-9613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-23
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH905111N00000X
OH3166111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH85636Medicare UPIN
OH0523953Medicare PIN
OH9316721Medicare PIN
OH47721Medicare UPIN
OH4054141Medicare PIN