1225071442 NPI number — PETERSEN HEALTH OPERATIONS, LLC

Table of content: (NPI 1225071442)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225071442 NPI number — PETERSEN HEALTH OPERATIONS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PETERSEN HEALTH OPERATIONS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225071442
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
830 W TRAILCREEK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61614-1862
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-691-8113
Provider Business Mailing Address Fax Number:
309-691-8622

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
107 N WATKINS STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CISNE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62823
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-673-2177
Provider Business Practice Location Address Fax Number:
618-673-2309
Provider Enumeration Date:
06/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PETERSEN
Authorized Official First Name:
MARK
Authorized Official Middle Name:
B
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
309-691-8113

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , with the licence number:  0047423 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com