Provider Demographics
NPI:1144203183
Name:PORTER COUNTY CHIROPRACTIC CLINIC INC.
Entity Type:Organization
Organization Name:PORTER COUNTY CHIROPRACTIC CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BEAUVAIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:219-465-5015
Mailing Address - Street 1:PO BOX 1009
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46384-1009
Mailing Address - Country:US
Mailing Address - Phone:219-465-5015
Mailing Address - Fax:219-548-3828
Practice Address - Street 1:2600 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-0970
Practice Address - Country:US
Practice Address - Phone:219-465-5015
Practice Address - Fax:219-548-3828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-23
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001767A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN350049047OtherRR MEDICARE GROUP NO
IL90000986OtherIL BC/BS GROUP NUMBER
IN000000105239OtherANTHEM GROUP NUMBER
IN200208460AMedicaid
IN000000105239OtherANTHEM GROUP NUMBER
IN200208460AMedicaid