Provider Demographics
NPI:1417946732
Name:PONTIAC NURSING HOME LLC
Entity Type:Organization
Organization Name:PONTIAC NURSING HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST. ADMINSTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:L
Authorized Official - Last Name:MOSHIER
Authorized Official - Suffix:
Authorized Official - Credentials:ASST ADMINISTRATOR
Authorized Official - Phone:315-343-1800
Mailing Address - Street 1:303 E RIVER RD
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-6400
Mailing Address - Country:US
Mailing Address - Phone:315-343-1900
Mailing Address - Fax:315-343-1821
Practice Address - Street 1:303 E RIVER RD
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-6400
Practice Address - Country:US
Practice Address - Phone:315-343-1900
Practice Address - Fax:315-343-1821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00308365Medicaid