Healthcare Provider Details

I. General information

NPI: 1346206315
Provider Name (Legal Business Name): HAVANA HCO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 N HARPHAM ST
HAVANA IL
62644
US

IV. Provider business mailing address

830 W TRAILCREEK DR
PEORIA IL
61614-1862
US

V. Phone/Fax

Practice location:
  • Phone: 309-543-6121
  • Fax: 309-543-1233
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 Number0046086
License Number StateIL

VIII. Authorized Official

Name: MARK B. PETERSEN
Title or Position: MANAGER
Credential:
Phone: 309-689-5880