Healthcare Provider Details

I. General information

NPI: 1275622003
Provider Name (Legal Business Name): PETERSEN HEALTH NETWORK, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 03/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 SHADWELL AVE
FLORA IL
62839-2310
US

IV. Provider business mailing address

830 W TRAILCREEK DR
PEORIA IL
61614-1862
US

V. Phone/Fax

Practice location:
  • Phone: 618-662-8361
  • Fax: 618-662-2811
Mailing address:
  • Phone: 309-691-8113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0038760
License Number StateIL

VIII. Authorized Official

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