Healthcare Provider Details

I. General information

NPI: 1538113535
Provider Name (Legal Business Name): PEKIN PROHEALTH INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 ILLINOIS AVE
MENDOTA IL
61342-1638
US

IV. Provider business mailing address

1416 N 8TH ST
PEKIN IL
61554-2103
US

V. Phone/Fax

Practice location:
  • Phone: 815-539-6506
  • Fax: 815-539-6708
Mailing address:
  • Phone: 309-347-4663
  • Fax: 309-347-5127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: MR. SCOTT LEIGH HAYNES
Title or Position: DIRECTOR
Credential:
Phone: 309-347-4663