Organization
PENTA GROUP INC.
Active
Other names
BRYAN MANOR
Organization subpart
No
Provider details
NPI number
Authorized official
GEORGIA MILLER (ADMINISTRATOR)
(618) 918-3770
Entity
Organization
Contact information
Practice address
2150 E MCCORD ST, CENTRALIA, IL 62801-6730
(618) 918-3770
Mailing address
PO BOX 687, CENTRALIA, IL 62801-9111
Taxonomy
Speciality
Code
Description
License number
State
315P00000X
Intellectual Disabilities Intermediate Care Facility
Primary
0033373
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
14G037
—
IL
Enumeration date
01/30/2007
Last updated
10/18/2010
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