Provider Demographics
NPI:1114093689
Name:SEQUOIA CHIROPRACTIC INC
Entity Type:Organization
Organization Name:SEQUOIA CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMIAH
Authorized Official - Middle Name:J
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-692-2121
Mailing Address - Street 1:8305 N. ALLEN ROAD
Mailing Address - Street 2:SUITE 7
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-1815
Mailing Address - Country:US
Mailing Address - Phone:309-692-2121
Mailing Address - Fax:309-692-4747
Practice Address - Street 1:8305 N. ALLEN ROAD
Practice Address - Street 2:SUITE 7
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-1815
Practice Address - Country:US
Practice Address - Phone:309-692-2121
Practice Address - Fax:309-692-4747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009678111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL7232024OtherBLUE CROSS BLUE SHIELD
U92942Medicare UPIN
ILU92942Medicare UPIN
IL203542Medicare ID - Type Unspecified