Healthcare Provider Details

I. General information

NPI: 1164622072
Provider Name (Legal Business Name): MIDWEST MULTICARE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 07/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4410 N KNOXVILLE AVE SUITE D
PEORIA IL
61614-6086
US

IV. Provider business mailing address

4410 N KNOXVILLE AVE SUITE D
PEORIA IL
61614-6086
US

V. Phone/Fax

Practice location:
  • Phone: 309-282-6419
  • Fax:
Mailing address:
  • Phone: 309-282-6419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038-009644
License Number StateIL

VIII. Authorized Official

Name: DR. BLAIR D HUNT
Title or Position: DIRECTOR
Credential: DC
Phone: 309-282-6419