Healthcare Provider Details

I. General information

NPI: 1245758630
Provider Name (Legal Business Name): KRISTIN ROSS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTIN DIERKER

II. Dates (important events)

Enumeration Date: 09/06/2017
Last Update Date: 08/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 NE MADISON AVE
PEORIA IL
61602-1109
US

IV. Provider business mailing address

3400 GRIFFIN AVE
PEKIN IL
61554-6246
US

V. Phone/Fax

Practice location:
  • Phone: 309-674-7874
  • Fax: 309-674-7874
Mailing address:
  • Phone: 309-347-4277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070023206
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: