Provider Demographics
NPI:1346358868
Name:PETERSON HEALTH CARE, INC.
Entity Type:Organization
Organization Name:PETERSON HEALTH CARE, INC.
Other - Org Name:PETERSON NURSING HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:W
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-528-4420
Mailing Address - Street 1:630 HOLLIDAY ST
Mailing Address - Street 2:
Mailing Address - City:OSAGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66523-1138
Mailing Address - Country:US
Mailing Address - Phone:785-528-4420
Mailing Address - Fax:785-528-3501
Practice Address - Street 1:630 HOLLIDAY ST
Practice Address - Street 2:
Practice Address - City:OSAGE CITY
Practice Address - State:KS
Practice Address - Zip Code:66523-1138
Practice Address - Country:US
Practice Address - Phone:785-528-4420
Practice Address - Fax:785-528-3501
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRYSTAL CARE CENTERS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-25
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSN070004314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100109480AMedicaid
KS1175OtherBLUE CROSS BLUE SHIELD
KS1175OtherBLUE CROSS BLUE SHIELD