Healthcare Provider Details

I. General information

NPI: 1184882490
Provider Name (Legal Business Name): PETERSEN HEALTH CARE - FARMER CITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2008
Last Update Date: 10/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 BROOKVIEW DR
FARMER CITY IL
61842-9746
US

IV. Provider business mailing address

830 W TRAILCREEK DR
PEORIA IL
61614-1862
US

V. Phone/Fax

Practice location:
  • Phone: 309-928-2118
  • Fax: 309-928-2313
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 Number
License Number State

VIII. Authorized Official

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