Provider Demographics
NPI:1235302308
Name:LIVINGSTON CO PUBLIC HLTH DEPT
Entity Type:Organization
Organization Name:LIVINGSTON CO PUBLIC HLTH DEPT
Other - Org Name:PONTIAC TOWNSHIP HIGH SCHOOL SCHOOL BASE HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MALINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-844-7174
Mailing Address - Street 1:310 E TORRANCE AVE
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-2748
Mailing Address - Country:US
Mailing Address - Phone:815-844-7174
Mailing Address - Fax:815-842-4104
Practice Address - Street 1:1100 E INDIANA AVE
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-1204
Practice Address - Country:US
Practice Address - Phone:815-844-6113
Practice Address - Fax:815-842-6517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-09
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6176414Medicaid