NPIMap

Organization Active NPI

Penta Nascent Corporation

Doing business as Park Place

  • Intellectual Disabilities Intermediate Care Facility
  • Centralia, IL
National Provider Identifier
1508086810
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X
License
0038646 Issued in IL
Legal business name
PENTA NASCENT CORPORATION
Doing business as
Park Place
Practice address
332 Country Club Rd
Centralia, IL 62801-3742
Phone
(618) 533-7922
NPI assigned
Apr 27, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Georgia Miller
Title
Ceo
Phone
(618) 548-4561

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Intellectual Disabilities Intermediate Care Facility 315P00000X 0038646 IL Primary

Addresses

Primary practice location

332 Country Club Rd
Centralia, IL 62801-3742

Mailing address

PO Box 1690
Centralia, IL 62801-9124

Other identifiers 1

IdentifierTypeStateIssuer
14G298MedicaidIL

Other names 1

  • PARK PLACE Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

Intermediate care facility for individuals with intellectual disabilities certification: CCN 14G298

Name & address match This certification has no NPI in the Medicare enrollment files. CMS publishes enrollment files for six facility types only, so it was connected to this NPI by matching the name and address CMS publishes for it.

Legal name
PARK PLACE - CENTRALIA
Certification status
Active
Provider type (POS)
Intermediate care facility for individuals with intellectual disabilities
Participating since
Jun 8, 1993
Last certification
Mar 8, 2024
Beds
16
Ownership / control type
Private (non-profit)
Facility address
332 Country Club Road
Centralia, IL 62801

National Provider Directory

National Provider Directory
Tax ID family
Colonial Apts4 organizations share this tax ID, including this one

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

Locations

332 Country Club Rd
Centralia, IL 62801
Phone (618) 533-7922

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1177632000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1508086810",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1690",
            "city": "CENTRALIA",
            "state": "IL",
            "postal_code": "628019124"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "332 COUNTRY CLUB RD",
            "city": "CENTRALIA",
            "state": "IL",
            "postal_code": "628013742",
            "telephone_number": "618-533-7922"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PENTA NASCENT CORPORATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-27",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "MILLER",
        "authorized_official_first_name": "GEORGIA",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "618-548-4561"
    },
    "taxonomies": [
        {
            "code": "315P00000X",
            "taxonomy_group": "",
            "desc": "Intermediate Care Facility, Intellectual Disabilities",
            "state": "IL",
            "license": "0038646",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "14G298",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PARK PLACE",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Centralia, IL

Sources for this page

Verify at the official NPI Registry.