Provider Demographics
NPI:1396930277
Name:PEORIA MEDICAL LLC
Entity type:Organization
Organization Name:PEORIA MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:918-743-3737
Mailing Address - Street 1:3345 S HARVARD AVE
Mailing Address - Street 2:STE #101
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-1812
Mailing Address - Country:US
Mailing Address - Phone:918-743-3737
Mailing Address - Fax:918-743-8383
Practice Address - Street 1:3345 S HARVARD AVE
Practice Address - Street 2:STE #101
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-1812
Practice Address - Country:US
Practice Address - Phone:918-743-3737
Practice Address - Fax:918-743-8383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3542111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1992897920OtherNPI