Healthcare Provider Details

I. General information

NPI: 1457679581
Provider Name (Legal Business Name): PROCTOR COMMUNITY HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2010
Last Update Date: 02/13/2023
Certification Date: 02/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5409 N KNOXVILLE AVE
PEORIA IL
61614-5069
US

IV. Provider business mailing address

5409 N KNOXVILLE AVE
PEORIA IL
61614-5069
US

V. Phone/Fax

Practice location:
  • Phone: 309-691-1000
  • Fax: 309-671-8265
Mailing address:
  • Phone: 309-672-4813
  • Fax: 309-671-8265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number0001925
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number1927324
License Number StateIL

VIII. Authorized Official

Name: MS. DEBORAH R. SIMON
Title or Position: PRESIDENT/CEO
Credential:
Phone: 309-672-5928