Provider Demographics
NPI:1861618829
Name:GREATER PEORIA PHYSICAL MEDICINE & REHAB
Entity type:Organization
Organization Name:GREATER PEORIA PHYSICAL MEDICINE & REHAB
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:J
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-693-2225
Mailing Address - Street 1:5001 N. UNIVERSITY STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614
Mailing Address - Country:US
Mailing Address - Phone:309-693-2225
Mailing Address - Fax:309-693-2228
Practice Address - Street 1:5001 N. UNIVERSITY STREET
Practice Address - Street 2:SUITE A
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614
Practice Address - Country:US
Practice Address - Phone:309-693-2225
Practice Address - Fax:309-693-2228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========OtherTAX ID