Basic Information
| Provider Information | |||||||||
| NPI: | 1932132115 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PETERSEN MANAGEMENT COMPANY, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | WHITE OAK REHABILITATION & HEALTH CARE CENTER | ||||||||
| 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: | 1700 WHITE ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628644349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6182424075 | ||||||||
| FaxNumber: | 6182424092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 05/23/2013 | ||||||||
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| AuthorizedOfficialLastName: | PETERSEN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3096918113 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PETERSEN HEALTH CARE II, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 743055934014 | 05 | IL | MEDICAID |