Provider Demographics
NPI:1538697834
Name:PA PETERSON AT THE CITADEL LLC
Entity Type:Organization
Organization Name:PA PETERSON AT THE CITADEL LLC
Other - Org Name:PA PETERSON AT THE CITADEL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARCELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-470-2044
Mailing Address - Street 1:3755 CHASE AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-4008
Mailing Address - Country:US
Mailing Address - Phone:224-470-2044
Mailing Address - Fax:224-470-2952
Practice Address - Street 1:1311 PARKVIEW AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-1818
Practice Address - Country:US
Practice Address - Phone:815-399-8832
Practice Address - Fax:815-399-8342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-31
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility