Healthcare Provider Details

I. General information

NPI: 1326004136
Provider Name (Legal Business Name): PETERSEN MANAGEMENT COMPANY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 05/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 GIVEN DR
FLORA IL
62839-1094
US

IV. Provider business mailing address

830 W TRAILCREEK DR
PEORIA IL
61614-1862
US

V. Phone/Fax

Practice location:
  • Phone: 618-662-8381
  • Fax: 618-662-9340
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 Number0046615
License Number StateIL

VIII. Authorized Official

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