Provider Demographics
NPI:1114423423
Name:BEAULIEU, GRAY ALAN (DC)
Entity Type:Individual
Prefix:
First Name:GRAY
Middle Name:ALAN
Last Name:BEAULIEU
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3448 FORESTBROOK RD
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-7931
Mailing Address - Country:US
Mailing Address - Phone:843-236-9810
Mailing Address - Fax:843-236-3702
Practice Address - Street 1:3448 FORESTBROOK RD
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-7931
Practice Address - Country:US
Practice Address - Phone:843-236-9810
Practice Address - Fax:843-236-3702
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-04
Last Update Date:2018-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4326111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor