Provider Demographics
NPI:1194703702
Name:PETERSEN HEALTH CARE VII LLC
Entity type:Organization
Organization Name:PETERSEN HEALTH CARE VII LLC
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:
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-691-8113
Mailing Address - Street 1:1 MASONIC WAY
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:IL
Mailing Address - Zip Code:61951-9467
Mailing Address - Country:US
Mailing Address - Phone:309-691-8113
Mailing Address - Fax:309-691-8622
Practice Address - Street 1:1 MASONIC WAY
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IL
Practice Address - Zip Code:61951-9467
Practice Address - Country:US
Practice Address - Phone:217-728-7394
Practice Address - Fax:217-728-4221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-04
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0010249314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146074Medicare Oscar/Certification