Healthcare Provider Details

I. General information

NPI: 1598702862
Provider Name (Legal Business Name): PETERSEN HEALTH PROPERTIES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 12/31/2019
Certification Date: 12/31/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

995 STATE ROUTE 127 S BOX B
JONESBORO IL
62952-2423
US

IV. Provider business mailing address

830 W TRAILCREEK DR
PEORIA IL
61614-1862
US

V. Phone/Fax

Practice location:
  • Phone: 618-833-7093
  • Fax: 618-833-4825
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 Number0043562
License Number StateIL

VIII. Authorized Official

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