Provider Demographics
NPI:1871739185
Name:WOODRIDGE OF PONITAC LLC
Entity type:Organization
Organization Name:WOODRIDGE OF PONITAC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-844-2100
Mailing Address - Street 1:120 NORTH DEERFIELD ROAD
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764
Mailing Address - Country:US
Mailing Address - Phone:815-844-2100
Mailing Address - Fax:815-844-2103
Practice Address - Street 1:120 NORTH DEERFIELD ROAD
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764
Practice Address - Country:US
Practice Address - Phone:815-844-2100
Practice Address - Fax:815-844-2103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-17
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========Medicaid