Healthcare Provider Details

I. General information

NPI: 1790616159
Provider Name (Legal Business Name): PENIEL CARE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5120 CECILIA ST SE
SALEM OR
97306-1725
US

IV. Provider business mailing address

5120 CECILIA ST SE
SALEM OR
97306-1725
US

V. Phone/Fax

Practice location:
  • Phone: 978-930-8119
  • Fax:
Mailing address:
  • Phone: 978-930-8119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: EMELDA WANJIRU NANCE
Title or Position: OWNER
Credential:
Phone: 978-930-8119