Provider Demographics
NPI:1629022447
Name:PROCTOR HEALTH SYSTEMS
Entity Type:Organization
Organization Name:PROCTOR HEALTH SYSTEMS
Other - Org Name:LAKE OF THE WOODS MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHIARAVALLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-689-6049
Mailing Address - Street 1:5401 N KNOXVILLE AVE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-5098
Mailing Address - Country:US
Mailing Address - Phone:309-689-6049
Mailing Address - Fax:309-689-6092
Practice Address - Street 1:12315 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:DUNLAP
Practice Address - State:IL
Practice Address - Zip Code:61525-9501
Practice Address - Country:US
Practice Address - Phone:309-243-5575
Practice Address - Fax:309-243-5764
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROCTOR HEALTH SYSTEMS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-19
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL242901Medicare ID - Type Unspecified