Provider Demographics
NPI:1336182138
Name:LAWYER, BEAU SHANNON (DC)
Entity Type:Individual
Prefix:
First Name:BEAU
Middle Name:SHANNON
Last Name:LAWYER
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 1:910 NEIL AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-1333
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212-2901
Practice Address - Country:US
Practice Address - Phone:614-486-6755
Practice Address - Fax:614-486-6781
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1915111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0914381Medicaid
OH9325221Medicare ID - Type UnspecifiedGROUP
OHU47753Medicare UPIN
OH0756192Medicare ID - Type UnspecifiedINDIVIDUAL