Provider Demographics
NPI:1417532136
Name:VAN WECHEL, BEAU JORDAN
Entity Type:Individual
Prefix:
First Name:BEAU
Middle Name:JORDAN
Last Name:VAN WECHEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8761 US HIGHWAY 42 STE C
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:KY
Mailing Address - Zip Code:41091-9316
Mailing Address - Country:US
Mailing Address - Phone:859-647-7780
Mailing Address - Fax:
Practice Address - Street 1:8761 US HIGHWAY 42 STE C
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:KY
Practice Address - Zip Code:41091-9316
Practice Address - Country:US
Practice Address - Phone:859-647-7780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-15
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA107840111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA107840OtherSTATE LICENSE