Provider Demographics
NPI:1780767897
Name:PETERSEN MANAGEMENT COMPANY, LLC
Entity type:Organization
Organization Name:PETERSEN MANAGEMENT COMPANY, LLC
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 1:5 DOCTORS PARK RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6224
Practice Address - Country:US
Practice Address - Phone:618-242-1064
Practice Address - Fax:618-242-7559
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PETERSEN HEALTH CARE II, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-23
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0039800313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL391516877001Medicaid