Provider Demographics
NPI:1619968823
Name:ASTA CARE CENTER OF PONTIAC LLC
Entity Type:Organization
Organization Name:ASTA CARE CENTER OF PONTIAC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-742-8822
Mailing Address - Street 1:300 W LOWELL
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-2614
Mailing Address - Country:US
Mailing Address - Phone:815-842-1181
Mailing Address - Fax:
Practice Address - Street 1:300 W LOWELL
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-2614
Practice Address - Country:US
Practice Address - Phone:815-842-1181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-04
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL00439683140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14-6010Medicare PIN