Provider Demographics
NPI:1740388263
Name:ELLSWORTH, BEAU J (DC)
Entity Type:Individual
Prefix:DR
First Name:BEAU
Middle Name:J
Last Name:ELLSWORTH
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 1:32 MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-4060
Mailing Address - Country:US
Mailing Address - Phone:847-318-1144
Mailing Address - Fax:847-318-8866
Practice Address - Street 1:32 MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068
Practice Address - Country:US
Practice Address - Phone:847-318-1144
Practice Address - Fax:847-318-8866
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011367111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor