Healthcare Provider Details

I. General information

NPI: 1417946732
Provider Name (Legal Business Name): PONTIAC NURSING HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 E RIVER RD
OSWEGO NY
13126-6400
US

IV. Provider business mailing address

303 E RIVER RD
OSWEGO NY
13126-6400
US

V. Phone/Fax

Practice location:
  • Phone: 315-343-1900
  • Fax: 315-343-1821
Mailing address:
  • Phone: 315-343-1900
  • Fax: 315-343-1821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3140N1450X
TaxonomyPediatric Skilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. THERESA L MOSHIER
Title or Position: ASST. ADMINSTRATOR
Credential: ASST. ADMINISTRATOR
Phone: 315-343-1800