Provider Demographics
NPI:1316283609
Name:JASPER COUNTY CHIROPRACTIC, INC.
Entity type:Organization
Organization Name:JASPER COUNTY CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:BEAUVAIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:219-987-3366
Mailing Address - Street 1:701 SOUTH HALLECK STREET
Mailing Address - Street 2:
Mailing Address - City:DEMOTTE
Mailing Address - State:IN
Mailing Address - Zip Code:46310
Mailing Address - Country:US
Mailing Address - Phone:219-987-3366
Mailing Address - Fax:219-987-3366
Practice Address - Street 1:701 SOUTH HALLECK STREET
Practice Address - Street 2:
Practice Address - City:DEMOTTE
Practice Address - State:IN
Practice Address - Zip Code:46310
Practice Address - Country:US
Practice Address - Phone:219-987-3366
Practice Address - Fax:219-987-3366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-14
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002084A111NR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0200XChiropractic ProvidersChiropractorRadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200444880AMedicaid
INP211070Medicare PIN