Provider Demographics
NPI:1710201793
Name:PETERSEN HEALTH CARE ROSEVILLE LLC
Entity Type:Organization
Organization Name:PETERSEN HEALTH CARE ROSEVILLE LLC
Other - Org Name:ROSEVILLE REHABILITATION & HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-691-8113
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:
Mailing Address - Fax:
Practice Address - Street 1:145 S CHAMBERLAIN ST
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:IL
Practice Address - Zip Code:61473-9581
Practice Address - Country:US
Practice Address - Phone:309-691-8113
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-20
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146020Medicare Oscar/Certification
IL146020Medicare PIN
IL146020Medicare UPIN