Healthcare Provider Details

I. General information

NPI: 1235176504
Provider Name (Legal Business Name): PETERSEN HEALTH OPERATIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 01/19/2022
Certification Date: 01/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 ILLINI DR
EAST PEORIA IL
61611-1840
US

IV. Provider business mailing address

830 W TRAILCREEK DR
PEORIA IL
61614-1862
US

V. Phone/Fax

Practice location:
  • Phone: 309-694-6446
  • Fax: 309-694-8705
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 Number0047472
License Number StateIL

VIII. Authorized Official

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