Provider Demographics
NPI:1760506554
Name:BEAUVAIS, DALE LEE (DC)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:LEE
Last Name:BEAUVAIS
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: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
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001767A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200155470CMedicaid
IL90000986OtherIL BC/BS GROUP NO
IN000000093417OtherANTHEM PROVIDER NUMBER
IN350049047OtherRR MEDICARE GROUP NO
IL90000986OtherIL BC/BS GROUP NO
INU73251Medicare UPIN