Healthcare Provider Details

I. General information

NPI: 1619083730
Provider Name (Legal Business Name): PETERSEN HEALTH CARE - ILLINI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 02/14/2024
Certification Date: 02/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 CURT DRIVE
CHAMPAIGN IL
61820
US

IV. Provider business mailing address

830 W. TRAILCREEK DRIVE
PEORIA IL
61614
US

V. Phone/Fax

Practice location:
  • Phone: 217-352-5707
  • Fax: 217-352-2607
Mailing address:
  • Phone: 309-691-8113
  • Fax: 309-691-8622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0042440
License Number StateIL

VIII. Authorized Official

Name: MARK B. PETERSEN
Title or Position: PRESIDENT
Credential:
Phone: 309-691-8113