Healthcare Provider Details

I. General information

NPI: 1306890108
Provider Name (Legal Business Name): PROCTOR HEALTH SYSTEMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 08/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 N KNOXVILLE AVE SUITE 300
PEORIA IL
61614-5098
US

IV. Provider business mailing address

5401 N KNOXVILLE AVE SUITE 209
PEORIA IL
61614-5098
US

V. Phone/Fax

Practice location:
  • Phone: 309-683-1200
  • Fax: 309-691-1705
Mailing address:
  • Phone: 309-689-6049
  • Fax: 309-689-6092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CARRIE CHIARAVALLE
Title or Position: DIRECTOR
Credential:
Phone: 309-689-6049