MEDICARE: PETERSEN HEALTH CARE, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	0046052	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265683429
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PETERSEN HEALTH CARE, INC

Provider Business Mailing Address
First Line	:	830 W TRAILCREEK DR
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61614-1862
Country	:	US
Telephone Number	:	309-691-8113
Fax Number	:

Provider Business Practice Location Address
First Line	:	601 N MORGAN ST
Second Line	:
City	:	BEMENT
State	:	IL
Zip	:	61813-1046
Country	:	US
Telephone Number	:	217-678-2191
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. MARK B PETERSEN
Credential	:
Telephone Number	:	309-691-8113

Provider Enumeration Date	:	10/07/2008
Last Update Date	:	10/07/2008

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