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General NPI Number Information
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NPI Number | 1881679579
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Entity Type | Organization
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Legal Business Name | GOOD SAMARITAN PONTIAC
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Dates
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Enumeration Date | 12/14/2005
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Last Update Date | 08/12/2020
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Provider Practice Location Address
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Address Line | 1225 S EWING DR
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City | PONTIAC
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State | IL
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Zip | 61764-9701
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Country | US
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Telephone | 815-844-5121
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Fax | 815-419-6000
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Provider Business Mailing Address
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Address Line | 1225 S EWING DR
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City | PONTIAC
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State | IL
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Zip | 61764-9701
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Country | US
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Telephone | 815-844-5121
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Fax | 815-419-6000
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | KIM WITTENBERG
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Credential | RN
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Telephone | 815-844-5121
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 313M00000X
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Taxonomy Name | Nursing Facility/Intermediate Care Facility
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License Number | 1630299
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 1630299
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License Number State | IL
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