Basic Information
| Provider Information | |||||||||
| NPI: | 1841444601 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PETERSEN HEALTH OPERATIONS, LLC | ||||||||
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| OtherOrganizationName: | COUNTRYVIEW CARE CENTER OF MACOMB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 830 W TRAILCREEK DR | ||||||||
| Address2: | |||||||||
| City: | PEORIA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 616141862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096918113 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 W GRANT ST | ||||||||
| Address2: | |||||||||
| City: | MACOMB | ||||||||
| State: | IL | ||||||||
| PostalCode: | 614552867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3098372386 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2008 | ||||||||
| LastUpdateDate: | 01/28/2020 | ||||||||
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| AuthorizedOfficialLastName: | PETERSEN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3096918113 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0047431 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.