MEDICARE: PETERSEN HEALTH CARE

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	313M00000X	Nursing Facility/Intermediate Care Facility	0026518	IL

General Provider Information

NPI Number	:	1689825820
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PETERSEN HEALTH CARE

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	:	129 S 1ST AVE
Second Line	:
City	:	CANTON
State	:	IL
Zip	:	61520-2612
Country	:	US
Telephone Number	:	309-691-8113
Fax Number	:

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

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

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Directions to “PETERSEN HEALTH CARE ” Practice Location

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