Healthcare Provider Details

I. General information

NPI: 1083019442
Provider Name (Legal Business Name): PONTIAC HEALTHCARE AND REHAB,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2014
Last Update Date: 11/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W LOWELL AVE
PONTIAC IL
61764-2614
US

IV. Provider business mailing address

300 W LOWELL AVE
PONTIAC IL
61764-2614
US

V. Phone/Fax

Practice location:
  • Phone: 815-842-1181
  • Fax: 815-842-3406
Mailing address:
  • Phone: 815-842-1181
  • Fax: 815-842-3406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number53264
License Number StateIL

VIII. Authorized Official

Name: MR. BRADLEY M. ALTER
Title or Position: MANAGING MEMBER
Credential:
Phone: 847-674-4700