Active NPI
Penta Group Inc.
- Intellectual Disabilities Intermediate Care Facility
- Centralia, IL
National Provider Identifier
1932246071
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Intellectual Disabilities Intermediate Care Facility
- License
- 0033373
- Legal business name
- PENTA GROUP INC.
- Practice address
- 2150 E McCord St
Centralia, IL 62801-6730 - Phone
- (618) 918-3770
- NPI assigned
- Jan 30, 2007
- Last updated
- Oct 18, 2010
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Georgia Miller
- Title
- Administrator
- Phone
- (618) 918-3770
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Intellectual Disabilities Intermediate Care Facility | 315P00000X | 0033373 | IL | Primary |
Addresses
Primary practice location
2150 E McCord St
Centralia, IL 62801-6730
Mailing address
PO Box 687
Centralia, IL 62801-9111
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 14G037 | Medicaid | IL |
Other names 1
- BRYAN MANOR
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
NPI to CCN mapping 1
The Medicare certification numbers (CCNs) connected to NPI 1932246071. Details of each certification follow.
Intermediate care facility for individuals with intellectual disabilities certification: CCN 14G037
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
- BRYAN MANOR
- Certification status
- Active
- Provider type (POS)
- Intermediate care facility for individuals with intellectual disabilities
- Participating since
- May 16, 1975
- Last certification
- Aug 2, 2024
- Beds
- 100
- Ownership / control type
- Private (non-profit)
- Facility address
- 2150 East McCord, PO Box 568
Centralia, IL 62801
National Provider Directory
National Provider Directory- Tax ID family
- Bryan Manor
Other organizations with this tax ID 1
Organizations that report the same tax identification number in the National Provider Directory.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1170115200000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1287360000000",
"number": "1932246071",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 687",
"city": "CENTRALIA",
"state": "IL",
"postal_code": "628019111"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2150 E MCCORD ST",
"city": "CENTRALIA",
"state": "IL",
"postal_code": "628016730",
"telephone_number": "618-918-3770"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "PENTA GROUP INC.",
"organizational_subpart": "NO",
"enumeration_date": "2007-01-30",
"last_updated": "2010-10-18",
"status": "A",
"authorized_official_last_name": "MILLER",
"authorized_official_first_name": "GEORGIA",
"authorized_official_title_or_position": "ADMINISTRATOR",
"authorized_official_telephone_number": "618-918-3770"
},
"taxonomies": [
{
"code": "315P00000X",
"taxonomy_group": "",
"desc": "Intermediate Care Facility, Intellectual Disabilities",
"state": "IL",
"license": "0033373",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "14G037",
"state": "IL"
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "BRYAN MANOR",
"code": "5",
"type": "Other Name"
}
]
}Other providers in Centralia, IL
- Brooke Felena Payne
- Dale D Pearce, APRN, FNP-C
- Kayla Ann Pearson
- Pediatric Group LLC
- Pediatric Group, LLC
- Penta Nascent Corporation (Diamondview)
- Penta Nascent Corporation (Park Place)
- Penta Nascent Corporation (Colonial Apts.)
- Rebekah Pharris
- Physician Services Corp of Southern Illinois (St marys good samaritan medical group)
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 18, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.