=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821296567
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PENTA C. ENTERPRICES, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3009 RAINBOW DR 142
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30034-1680
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-243-1992
-----------------------------------------------------
Fax | 404-243-4903
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3009 RAINBOW DR 142
-----------------------------------------------------
City | DECATUR
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30034-1680
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-243-1992
-----------------------------------------------------
Fax | 404-243-4903
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | ALICE CANNON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-243-1992
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 101YM0800X
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------