=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134764517
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEORIA SPINE AND SPORT LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2019
-----------------------------------------------------
Last Update Date | 08/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8305 N ALLEN RD STE 7
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61615-1816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-621-1410
-----------------------------------------------------
Fax | 309-315-1220
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 316 E EDGEWOOD ST
-----------------------------------------------------
City | MORTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61550-2534
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-369-5474
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | DR. JACLYN JEAN DEIG
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 805-266-9619
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------