Provider Demographics
NPI:1639644222
Name:BLAKELEY, BEAU (DC)
Entity Type:Individual
Prefix:DR
First Name:BEAU
Middle Name:
Last Name:BLAKELEY
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 1:320 W BURLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2363
Mailing Address - Country:US
Mailing Address - Phone:708-497-2441
Mailing Address - Fax:
Practice Address - Street 1:320 W BURLINGTON AVE
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2363
Practice Address - Country:US
Practice Address - Phone:708-497-2441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038013267111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No111NN0400XChiropractic ProvidersChiropractorNeurology