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General NPI Number Information
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NPI Number | 1619968823
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Entity Type | Organization
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Legal Business Name | ASTA CARE CENTER OF PONTIAC LLC
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Dates
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Enumeration Date | 11/04/2005
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Last Update Date | 05/10/2013
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Provider Practice Location Address
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Address Line | 300 W LOWELL
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City | PONTIAC
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State | IL
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Zip | 61764-2614
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Country | US
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Telephone | 815-842-1181
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Fax |
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Provider Business Mailing Address
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Address Line | 300 W LOWELL
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City | PONTIAC
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State | IL
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Zip | 61764-2614
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Country | US
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Telephone | 815-842-1181
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MICHAEL GILLMAN
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Credential |
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Telephone | 847-742-8822
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3140N1450X
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Taxonomy Name | Pediatric Skilled Nursing Facility
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License Number | 0043968
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License Number State | IL
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