Basic Information
| Provider Information | |||||||||
| NPI: | 1962468769 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PETERSEN HEALTH CARE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEADOWLAWN HEALTH CARE | ||||||||
| 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: | 4656 W KIMBERLY RD | ||||||||
| Address2: | |||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528067111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633915150 | ||||||||
| FaxNumber: | 5633913901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | PETERSEN | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3096918113 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 820624 | IA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0809459 | 05 | IA | MEDICAID |