Healthcare Provider Details

I. General information

NPI: 1982621694
Provider Name (Legal Business Name): BREATH OF LIFE LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 SW ADAMS ST
PEORIA IL
61602-1803
US

IV. Provider business mailing address

1418 W GIFT AVE
PEORIA IL
61604-2559
US

V. Phone/Fax

Practice location:
  • Phone: 309-676-5645
  • Fax:
Mailing address:
  • Phone: 309-686-7135
  • Fax: 309-686-7133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227800000X
TaxonomyCertified Respiratory Therapist
License Number
License Number StateIL

VIII. Authorized Official

Name: PIZZARRO JUAN PICKETT
Title or Position: RESPIRATORY THERAPIST
Credential: CRT,RCP
Phone: 309-645-7430