Healthcare Provider Details

I. General information

NPI: 1003943705
Provider Name (Legal Business Name): PETERSEN HEALTH BUSINESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 07/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 NORTH B STREET
LA HARPE IL
61450-0547
US

IV. Provider business mailing address

830 W TRAILCREEK DRIVE
PEORIA IL
61614
US

V. Phone/Fax

Practice location:
  • Phone: 217-659-3222
  • Fax: 217-659-3017
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 Number0035741
License Number StateIL

VIII. Authorized Official

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