Provider Demographics
NPI:1164475976
Name:NECK TO BACK PEORIA LLC
Entity Type:Organization
Organization Name:NECK TO BACK PEORIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPTROLLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-227-9900
Mailing Address - Street 1:7177 CRIMSON RIDGE DR
Mailing Address - Street 2:SUITE 14
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-6208
Mailing Address - Country:US
Mailing Address - Phone:815-227-9900
Mailing Address - Fax:815-227-9805
Practice Address - Street 1:5105 N GLEN PARK PLACE RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4688
Practice Address - Country:US
Practice Address - Phone:309-691-9300
Practice Address - Fax:309-691-9403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
213046Medicare ID - Type Unspecified