Provider Demographics
NPI:1649236449
Name:KEWANEE HCO, LLC
Entity Type:Organization
Organization Name:KEWANEE HCO, LLC
Other - Org Name:KEWANEE CARE HOME
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 1:144 JUNIOR AVE
Practice Address - Street 2:
Practice Address - City:KEWANEE
Practice Address - State:IL
Practice Address - Zip Code:61443-2554
Practice Address - Country:US
Practice Address - Phone:309-853-4429
Practice Address - Fax:309-853-9209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-21
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0026518314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL37-1068286001Medicaid
IL145968Medicare Oscar/Certification