Provider Demographics
NPI:1942467105
Name:KHOURY CHIROPRACTIC INC
Entity Type:Organization
Organization Name:KHOURY CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:KHOURY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-693-1212
Mailing Address - Street 1:2015 W GLEN AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4690
Mailing Address - Country:US
Mailing Address - Phone:309-693-1212
Mailing Address - Fax:309-693-2147
Practice Address - Street 1:2015 W GLEN AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4690
Practice Address - Country:US
Practice Address - Phone:309-693-1212
Practice Address - Fax:309-693-2147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038009705111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038009705Medicaid
IL038009705Medicaid