Provider Demographics
NPI:1184882490
Name:PETERSEN HEALTH CARE - FARMER CITY
Entity type:Organization
Organization Name:PETERSEN HEALTH CARE - FARMER CITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:B
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-691-8113
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:309-691-8113
Mailing Address - Fax:309-691-8622
Practice Address - Street 1:404 BROOKVIEW DR
Practice Address - Street 2:
Practice Address - City:FARMER CITY
Practice Address - State:IL
Practice Address - Zip Code:61842-9746
Practice Address - Country:US
Practice Address - Phone:309-928-2118
Practice Address - Fax:309-928-2313
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-23
Last Update Date:2008-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146104Medicare Oscar/Certification