Healthcare Provider Details

I. General information

NPI: 1811139876
Provider Name (Legal Business Name): WESTSIDE HCO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2009
Last Update Date: 12/02/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 N COLUMBIA ST
WEST FRANKFORT IL
62896-1859
US

IV. Provider business mailing address

830 W TRAILCREEK DR
PEORIA IL
61614-1862
US

V. Phone/Fax

Practice location:
  • Phone: 618-932-2109
  • Fax:
Mailing address:
  • Phone: 309-691-8113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0053488
License Number StateIL

VIII. Authorized Official

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