Provider Demographics
NPI:1467608307
Name:NEW LIFE CHIROPRACTIC OF PEORIA, LTD.
Entity Type:Organization
Organization Name:NEW LIFE CHIROPRACTIC OF PEORIA, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHEENA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOSEPH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-693-3800
Mailing Address - Street 1:800 W TRAILCREEK DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-1862
Mailing Address - Country:US
Mailing Address - Phone:309-693-3800
Mailing Address - Fax:309-693-7816
Practice Address - Street 1:800 W TRAILCREEK DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-1862
Practice Address - Country:US
Practice Address - Phone:309-693-3800
Practice Address - Fax:309-693-7816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-12
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011225111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL217041Medicare UPIN