Havana Hco, LLC

Primary specialty

Skilled Nursing FacilityTaxonomy code 314000000X

Legal business name

HAVANA HCO, LLC

Practice address

609 N Harpham St
Havana, IL 62644-1249

Phone

(309) 543-6121

NPI assigned

Feb 17, 2020

Organization subpart

No

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

Authorized official

Name

Mark B. Petersen

Title

Manager

Phone

(309) 691-8113

Specialties & licenses 1

Addresses

Locations

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

{
    "created_epoch": "1581897600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1581897600000",
    "number": "1760015929",
    "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": "309-689-5880"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "609 N HARPHAM ST",
            "city": "HAVANA",
            "state": "IL",
            "postal_code": "626441249",
            "telephone_number": "309-543-6121"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HAVANA HCO, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-02-17",
        "last_updated": "2020-02-17",
        "certification_date": "2020-02-17",
        "status": "A",
        "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"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Marcie L. Ganson, PT, DPT, MBA
• Randall Joe Goodman II, DPT
• Becky Jane Hart, LCSW
• Havana Cusd 126
• Havana Hco, LLC
• Alycia Helling, M.S., CCC-SLP
• Stuart Hickerson
• Highland Park CVS LLC
• Chase Holtman
• HSHS Medical Group Inc

• All providers in Havana, IL
• Skilled Nursing Facility in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 17, 2020; 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.