Basic Information
| Provider Information | |||||||||
| NPI: | 1194703702 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PETERSEN HEALTH CARE VII LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MASON POINT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 MASONIC WAY | ||||||||
| Address2: | |||||||||
| City: | SULLIVAN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619519467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096918113 | ||||||||
| FaxNumber: | 3096918622 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MASONIC WAY | ||||||||
| Address2: | |||||||||
| City: | SULLIVAN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619519467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177287394 | ||||||||
| FaxNumber: | 2177284221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 07/27/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PETERSEN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3096918113 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0010249 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.