Provider Demographics
NPI:1003393430
Name:PEYTON, NICHOLAS (ATC)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:PEYTON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 N ALLEN RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-3294
Mailing Address - Country:US
Mailing Address - Phone:309-691-1400
Mailing Address - Fax:309-689-7094
Practice Address - Street 1:6000 N ALLEN RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-3294
Practice Address - Country:US
Practice Address - Phone:309-689-7044
Practice Address - Fax:309-689-7094
Is Sole Proprietor?:No
Enumeration Date:2018-07-27
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0920142255A2300X
IL0960050702255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer