Provider Demographics
NPI:1740433531
Name:PEKIN PROHEALTH INC
Entity type:Organization
Organization Name:PEKIN PROHEALTH INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-353-0787
Mailing Address - Street 1:600 S 13TH ST
Mailing Address - Street 2:
Mailing Address - City:PEKIN
Mailing Address - State:IL
Mailing Address - Zip Code:61554-4936
Mailing Address - Country:US
Mailing Address - Phone:309-353-0902
Mailing Address - Fax:309-347-2623
Practice Address - Street 1:19 OLT AVE
Practice Address - Street 2:
Practice Address - City:PEKIN
Practice Address - State:IL
Practice Address - Zip Code:61554-6216
Practice Address - Country:US
Practice Address - Phone:309-353-0902
Practice Address - Fax:309-347-2623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-24
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL009180787261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL009180787Medicaid
IL09015685OtherBCBS
IL569310Medicare PIN