Provider Demographics
NPI:1376208983
Name:PEORIA NON- EMERGENCY MEDICAL TRANSPORT
Entity Type:Organization
Organization Name:PEORIA NON- EMERGENCY MEDICAL TRANSPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CORY
Authorized Official - Middle Name:E
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-857-1165
Mailing Address - Street 1:3624 W CASSADAGA CT
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-3952
Mailing Address - Country:US
Mailing Address - Phone:309-857-1165
Mailing Address - Fax:
Practice Address - Street 1:3624 W CASSADAGA CT
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-3952
Practice Address - Country:US
Practice Address - Phone:309-857-1165
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)