Provider Demographics
NPI:1720101165
Name:BEASLEY, GREGORY W (DC)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:W
Last Name:BEASLEY
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 1:9212 EVERGREEN WAY
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204
Mailing Address - Country:US
Mailing Address - Phone:425-353-7246
Mailing Address - Fax:425-267-0961
Practice Address - Street 1:9212 EVERGREEN WAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98204-7125
Practice Address - Country:US
Practice Address - Phone:425-353-7246
Practice Address - Fax:425-267-0961
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACHOOOO2828111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA124204OtherDEPT OF L&I
WAU41895Medicare UPIN
WAAB18615Medicare ID - Type Unspecified