Provider Demographics
NPI:1609160654
Name:MILES, BENJAMIN (DC)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:MILES
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 N KNOXVILLE AVE
Mailing Address - Street 2:STE 104
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5098
Mailing Address - Country:US
Mailing Address - Phone:309-692-0123
Mailing Address - Fax:309-692-0184
Practice Address - Street 1:5401 N KNOXVILLE AVE
Practice Address - Street 2:STE 104
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-5098
Practice Address - Country:US
Practice Address - Phone:309-692-0123
Practice Address - Fax:309-692-0184
Is Sole Proprietor?:No
Enumeration Date:2011-06-07
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-011932111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038-011932OtherSTATE LICENSE
IL038-011932OtherSTATE LICENSE