Provider Demographics
NPI:1275076028
Name:PONTIAC SUPPORTIVE LIVING, LLC
Entity Type:Organization
Organization Name:PONTIAC SUPPORTIVE LIVING, LLC
Other - Org Name:POINTE AT PONTIAC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:STEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-230-7762
Mailing Address - Street 1:120 N DEERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-9403
Mailing Address - Country:US
Mailing Address - Phone:815-844-6300
Mailing Address - Fax:815-844-6301
Practice Address - Street 1:120 N DEERFIELD RD
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-9403
Practice Address - Country:US
Practice Address - Phone:815-844-6300
Practice Address - Fax:815-844-6301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-28
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility