Petersen Management Company, LLC

Primary specialty

Skilled Nursing FacilityTaxonomy code 314000000X

License

0046037 Issued in IL

Legal business name

PETERSEN MANAGEMENT COMPANY, LLC

Doing business as

Palm Terrace of Mattoon

Practice address

1000 Palm Ave
Mattoon, IL 61938-6031

Phone

(217) 234-7403

Fax

(217) 258-6642

NPI assigned

Apr 21, 2006

Organization subpart

Yes

Parent organization

PETERSEN HEALTH CARE II, INC.As reported in NPPES

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

Authorized official

Name

Mark B. Petersen

Title

President

Phone

(309) 691-8113

Specialties & licenses 1

Addresses

Other identifiers 1

Other names 1

• Palm Terrace of Mattoon Doing business as

Part of

Petersen Health Care LL Inc

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

{
    "created_epoch": "1145577600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1369267200000",
    "number": "1487610291",
    "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": "1000 PALM AVE",
            "city": "MATTOON",
            "state": "IL",
            "postal_code": "619386031",
            "telephone_number": "217-234-7403",
            "fax_number": "217-258-6642"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PETERSEN MANAGEMENT COMPANY, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PETERSEN HEALTH CARE II, INC.",
        "enumeration_date": "2006-04-21",
        "last_updated": "2013-05-23",
        "status": "A",
        "authorized_official_last_name": "PETERSEN",
        "authorized_official_first_name": "MARK",
        "authorized_official_middle_name": "B.",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "309-691-8113"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "IL",
            "license": "0046037",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "74-3055934001",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Palm Terrace of Mattoon",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Adrian Pelayo, RSA
• Dwight Pentzien, D.O.
• Kimberly Penza, SLPA
• Dominic Perrino, D.O.
• Petersen Health Care II, Inc
• Pharmax Inc.
• Philco Dental Group LLC - Mattoon
• Philip B. Kepp, DDS,PC
• Kali Pierce, BA
• Ryan Robert Pine, M.D.

• Skilled Nursing Facility in Mattoon, IL
• Providers in Mattoon, IL by specialty
• Skilled Nursing Facility in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 23, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.