1184784118 NPI number — COUNTY OF PEORIA

Table of content: (NPI 1184784118)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184784118 NPI number — COUNTY OF PEORIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTY OF PEORIA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
HEDDINGTON OAKS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184784118
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
324 MAIN ST
Provider Second Line Business Mailing Address:
ROOM 501
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61602-2331
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-677-6233
Provider Business Mailing Address Fax Number:
309-495-4608

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2223 W HEADING AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61604-5139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-636-3600
Provider Business Practice Location Address Fax Number:
309-636-3610
Provider Enumeration Date:
12/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CURTIS LUTHER
Authorized Official First Name:
LORI
Authorized Official Middle Name:
Authorized Official Title or Position:
COUNTY ADMINISTRATOR
Authorized Official Telephone Number:
309-672-6056

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  1737473 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 069333049001 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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