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NPI Code Detail

MEDICARE: PETERSEN MANAGEMENT COMPANY, LLC

MEDICARE: PETERSEN MANAGEMENT COMPANY, 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 Facility0046615IL

Other Identifiers

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

General Provider Information

NPI Number : 1326004136
Entity Type Code : Organization
Provider Name (Legal Business Name) : PETERSEN MANAGEMENT COMPANY, 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 : 309-691-8622
Provider Business Practice Location Address
First Line : 232 GIVEN DR
Second Line :
City : FLORA
State : IL
Zip : 62839-1094
Country : US
Telephone Number : 618-662-8381
Fax Number : 618-662-9340
Authorized Official
Title or Position : PRESIDENT
Name : MARK B. PETERSEN
Credential :
Telephone Number : 309-691-8113
Provider Enumeration Date : 04/21/2006
Last Update Date : 05/23/2013

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Directions to “PETERSEN MANAGEMENT COMPANY, LLC ” Practice Location

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