Healthcare Provider Details

I. General information

NPI: 1396830154
Provider Name (Legal Business Name): PETERSEN COMPANIES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 10/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 N MARIETTA ST
GREENUP IL
62428-1103
US

IV. Provider business mailing address

830 W TRAILCREEK DR
PEORIA IL
61614-1862
US

V. Phone/Fax

Practice location:
  • Phone: 217-923-3186
  • Fax: 217-923-5226
Mailing address:
  • Phone: 309-691-8113
  • Fax: 309-691-8622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number0004929
License Number StateIL

VIII. Authorized Official

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