Provider Demographics
NPI:1265527931
Name:PETERSEN HEALTH SYSTEMS, INS
Entity type:Organization
Organization Name:PETERSEN HEALTH SYSTEMS, INS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
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:309-691-8113
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 1:1 COURTYARD BLVD
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:IL
Practice Address - Zip Code:61462-1086
Practice Address - Country:US
Practice Address - Phone:309-734-9355
Practice Address - Fax:309-734-9394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL5101693310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility