Organization
GOOD SAMARITAN PONTIAC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KIM WITTENBERG RN (ADMINISTRATOR)
(815) 844-5121
Entity
Organization
Contact information
Practice address
1225 S EWING DR, PONTIAC, IL 61764-9701
(815) 844-5121
(815) 419-6000
Mailing address
1225 S EWING DR, PONTIAC, IL 61764-9701
(815) 844-5121
(815) 419-6000
Taxonomy
Speciality
Code
Description
License number
State
313M00000X
Nursing Facility/Intermediate Care Facility
1630299
IL
314000000X
Skilled Nursing Facility
Primary
1630299
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0010942
—
IL
Enumeration date
12/14/2005
Last updated
08/12/2020
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