Basic Information
| Provider Information | |||||||||
| NPI: | 1598918385 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PETERSEN HEALTH CARE II, INC. | ||||||||
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| OtherOrganizationName: | COURTYARD ESTATES OF SULLIVAN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 830 W TRAILCREEK DR | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616141862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096918113 | ||||||||
| FaxNumber: | 3096918622 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 COURTYARD BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | SULLIVAN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619517001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2177284300 | ||||||||
| FaxNumber: | 2177282165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2008 | ||||||||
| LastUpdateDate: | 10/24/2008 | ||||||||
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| AuthorizedOfficialLastName: | PETERSEN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3096918113 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.