=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467670109
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PENTA NASCENT CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 RODDY RD
-----------------------------------------------------
City | SALEM
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62881-3836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-548-0353
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1690
-----------------------------------------------------
City | CENTRALIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62801-9124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | GEORGIA MILLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 618-548-4561
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 315P00000X
-----------------------------------------------------
Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
-----------------------------------------------------
License Number | 0036004
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------