Healthcare Provider Details

I. General information

NPI: 1164475976
Provider Name (Legal Business Name): NECK TO BACK PEORIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5105 N GLEN PARK PLACE RD
PEORIA IL
61614-4688
US

IV. Provider business mailing address

7177 CRIMSON RIDGE DR SUITE 14
ROCKFORD IL
61107-6208
US

V. Phone/Fax

Practice location:
  • Phone: 309-691-9300
  • Fax: 309-691-9403
Mailing address:
  • Phone: 815-227-9900
  • Fax: 815-227-9805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name: MRS. WENDY NEWMAN
Title or Position: COMPTROLLER
Credential:
Phone: 815-227-9900