NPIMap

Organization Active NPI

Petersen Health Operations, LLC

Doing business as Fondulac Rehabilitation & Health Care Center

  • Skilled Nursing Facility
  • East Peoria, IL
National Provider Identifier
1235176504
Registry record updated Jan 19, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
License
0047472 Issued in IL
Legal business name
PETERSEN HEALTH OPERATIONS, LLC
Doing business as
Fondulac Rehabilitation & Health Care Center
Practice address
901 Illini Dr
East Peoria, IL 61611-1840
Phone
(309) 694-6446
Fax
(309) 694-8705
NPI assigned
Jun 2, 2006
Last updated
Jan 19, 2022By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 19, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mark B. Petersen
Title
General Manager
Phone
(309) 691-8113

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X 0047472 IL Primary

Addresses

Primary practice location

901 Illini Dr
East Peoria, IL 61611-1840

Mailing address

830 W Trailcreek Dr
Peoria, IL 61614-1862
Phone (309) 691-8113

Other names 1

  • Fondulac Rehabilitation & Health Care Center Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IL

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20051227000342 IL Part A Provider - Skilled Nursing Facility 8921020470 Practice locations: East Peoria, IL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1235176504. Details of each certification follow.

Skilled nursing facility certification: CCN 145266

Legal name
PETERSEN HEALTH OPERATIONS LLC
Doing business as
FONDULAC REHABILITATION & HEALTH CARE CENTER
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Dec 26, 1973
Last certification
Aug 21, 2024
Beds
98
Ownership / control type
Corporation
Most recent change of ownership
Sep 30, 2005
Organization structure
LLCProprietary
Incorporated
Jul 29, 2005 in IL
Enrollment address
901 Illini Dr
East Peoria, IL 61611-1840

Other NPIs with the same Medicare PAC ID 5

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Care Compare: Nursing home

Medicare Care Compare
Listed as
Fondulac Rehabilitation and Health Care CenterCCN 145266 · All quality measures
Overall star rating
1 of 5
Health inspections
1 of 5
Staffing
1 of 5
Quality measures
3 of 5
Type
Medicare and Medicaid
Ownership
For profit - Corporation
Certified
Dec 26, 1973
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
9872.0 residents per day on average
Special focus status
SFF Candidate
Abuse citation
Cited for abuse (Care Compare abuse icon)
Penalties (3 years)
3Fines totaling $146,601

Processed by Care Compare on Aug 1, 2026.

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 2

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Mark B Petersen Individual 5% Or Greater Direct Ownership InterestOfficer Sep 30, 2005
Ryan Mehaffy Individual W-2 Managing Employee Jan 9, 2017

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1149206400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1642550400000",
    "number": "1235176504",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "830 W TRAILCREEK DR",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616141862",
            "telephone_number": "309-691-8113",
            "fax_number": "309-691-8622"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "901 ILLINI DR",
            "city": "EAST PEORIA",
            "state": "IL",
            "postal_code": "616111840",
            "telephone_number": "309-694-6446",
            "fax_number": "309-694-8705"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PETERSEN HEALTH OPERATIONS, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-02",
        "last_updated": "2022-01-19",
        "certification_date": "2022-01-19",
        "status": "A",
        "authorized_official_last_name": "PETERSEN",
        "authorized_official_first_name": "MARK",
        "authorized_official_middle_name": "B.",
        "authorized_official_title_or_position": "GENERAL MANAGER",
        "authorized_official_telephone_number": "309-691-8113"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "IL",
            "license": "0047472",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Fondulac Rehabilitation & Health Care Center",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in East Peoria, IL

Sources for this page

Verify at the official NPI Registry.