Basic Information
| Provider Information | |||||||||
| NPI: | 1003943705 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PETERSEN HEALTH BUSINESS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LAHARPE DAVIER HCC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 830 W TRAILCREEK DRIVE | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096918113 | ||||||||
| FaxNumber: | 3096918622 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 NORTH B STREET | ||||||||
| Address2: | |||||||||
| City: | LA HARPE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 614500547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2176593222 | ||||||||
| FaxNumber: | 2176593017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 07/22/2015 | ||||||||
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| AuthorizedOfficialLastName: | PETERSEN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3096918113 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0035741 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.