Provider Demographics
NPI:1013056456
Name:GREGERSEN, BEAU ANTHONY (DC)
Entity Type:Individual
Prefix:DR
First Name:BEAU
Middle Name:ANTHONY
Last Name:GREGERSEN
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 1:330 W 58TH ST
Mailing Address - Street 2:SUITE# 407
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-1827
Mailing Address - Country:US
Mailing Address - Phone:212-765-6470
Mailing Address - Fax:212-333-7346
Practice Address - Street 1:330 W 58TH ST
Practice Address - Street 2:SUITE# 407
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1827
Practice Address - Country:US
Practice Address - Phone:212-765-6470
Practice Address - Fax:212-333-7346
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX011304-1111N00000X
TX10129111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB162109Medicare PIN