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NPI Code Detail

MEDICARE: PETERSEN HEALTH NETWORK, LLC

MEDICARE: PETERSEN HEALTH NETWORK, LLC
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
1314000000XSkilled Nursing Facility0038760IL

General Provider Information

NPI Number : 1275622003
Entity Type Code : Organization
Provider Name (Legal Business Name) : PETERSEN HEALTH NETWORK, LLC
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 : 701 SHADWELL AVE
Second Line :
City : FLORA
State : IL
Zip : 62839-2310
Country : US
Telephone Number : 618-662-8361
Fax Number : 618-662-2811
Authorized Official
Title or Position : PRESIDENT
Name : MARK B PETERSEN
Credential :
Telephone Number : 309-691-8113
Provider Enumeration Date : 10/12/2006
Last Update Date : 03/18/2017

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