Healthcare Provider Details

I. General information

NPI: 1528127735
Provider Name (Legal Business Name): WILLIAM TED MLOTEK DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 08/16/2010
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: 309-282-6003
Mailing address:
  • Phone: 309-282-6419
  • Fax: 309-282-6003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038009080
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: