Healthcare Provider Details

I. General information

NPI: 1679550644
Provider Name (Legal Business Name): LEBANON HCO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 09/11/2020
Certification Date: 09/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 N ALTON ST
LEBANON IL
62254-1103
US

IV. Provider business mailing address

830 W TRAILCREEK DR
PEORIA IL
61614-1862
US

V. Phone/Fax

Practice location:
  • Phone: 618-537-4401
  • Fax:
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 Number0016964
License Number StateIL

VIII. Authorized Official

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