Organization
PENTA NASCENT CORPORATION
Active
Other names
PARK PLACE
Organization subpart
No
Provider details
NPI number
Authorized official
GEORGIA MILLER (CEO)
(618) 548-4561
Entity
Organization
Contact information
Practice address
332 COUNTRY CLUB RD, CENTRALIA, IL 62801-3742
(618) 533-7922
Mailing address
PO BOX 1690, CENTRALIA, IL 62801-9124
Taxonomy
Speciality
Code
Description
License number
State
315P00000X
Intellectual Disabilities Intermediate Care Facility
Primary
0038646
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
14G298
—
IL
Enumeration date
04/27/2007
Last updated
08/22/2020
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