Basic Information
| Provider Information | |||||||||
| NPI: | 1891108668 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PA PETERSON LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE VILLA AT PA PETERSON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 6400 SHAFER CT | ||||||||
| Address2: | SUITE 475 | ||||||||
| City: | ROSEMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600184914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153998832 | ||||||||
| FaxNumber: | 8153998342 | ||||||||
| Practice Location | |||||||||
| Address1: | 1311 PARKVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611071818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153998832 | ||||||||
| FaxNumber: | 8153998342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2014 | ||||||||
| LastUpdateDate: | 06/09/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MEEHAN | ||||||||
| AuthorizedOfficialFirstName: | FRANCES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ATTORNEY | ||||||||
| AuthorizedOfficialTelephone: | 3125212467 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.