Healthcare Provider Details

I. General information

NPI: 1386802775
Provider Name (Legal Business Name): CENTRAL ILLINOIS NERVE TESTING LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2008
Last Update Date: 09/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3322 W WILLOW KNOLLS RD
PEORIA IL
61614-8148
US

IV. Provider business mailing address

614 SPRING ST
PEORIA IL
61603-4133
US

V. Phone/Fax

Practice location:
  • Phone: 309-691-1727
  • Fax: 309-637-2325
Mailing address:
  • Phone: 309-637-3668
  • Fax: 309-637-2325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number016003701
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number016003701
License Number StateIL

VIII. Authorized Official

Name: DR. JOHN D RUFF
Title or Position: DR
Credential: DPM
Phone: 309-691-1727