Provider Demographics
NPI:1346206315
Name:HAVANA HCO, LLC
Entity Type:Organization
Organization Name:HAVANA HCO, LLC
Other - Org Name:HAVANA HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:B
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-689-5880
Mailing Address - Street 1:830 W TRAILCREEK DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-1862
Mailing Address - Country:US
Mailing Address - Phone:309-691-8113
Mailing Address - Fax:309-691-8622
Practice Address - Street 1:609 N HARPHAM ST
Practice Address - Street 2:
Practice Address - City:HAVANA
Practice Address - State:IL
Practice Address - Zip Code:62644
Practice Address - Country:US
Practice Address - Phone:309-543-6121
Practice Address - Fax:309-543-1233
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PETERSEN HEALTH CARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-26
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0046086314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL37-1068286007Medicaid
IL37-1068286007Medicaid