Healthcare Provider Details

I. General information

NPI: 1881679579
Provider Name (Legal Business Name): GOOD SAMARITAN PONTIAC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 S EWING DR
PONTIAC IL
61764-9701
US

IV. Provider business mailing address

1225 S EWING DR
PONTIAC IL
61764-9701
US

V. Phone/Fax

Practice location:
  • Phone: 815-844-5121
  • Fax: 815-419-6000
Mailing address:
  • Phone: 815-844-5121
  • Fax: 815-419-6000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number1630299
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1630299
License Number StateIL

VIII. Authorized Official

Name: KIM WITTENBERG
Title or Position: ADMINISTRATOR
Credential: RN
Phone: 815-844-5121