PENTA NASCENT CORPORATION NPI 1467670109

NPI Information

  • NPI: 1467670109
  • Provider Name: PENTA NASCENT CORPORATION
  • Classification: Intermediate Care Facility, Intellectual Disabilities - 315P00000X
  • Entity Type: Organization
  • Doing Business As: LYNWOOD ESTATES
  • CLIA Number: 14D1032094
  • Address: 301 RODDY RD
    SALEM, IL
    ZIP 62881
  • Phone: (618) 548-0353

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NPI Details

PENTA NASCENT CORPORATION is an intermediate care facility mentally retarded in Salem, IL. The provider is an intermediate care facility providing services for individuals with intellectual disabilities. PENTA NASCENT CORPORATION NPI is 1467670109. The provider is registered as an organization entity type.
The provider Is Doing Business As Lynwood Estates.

The provider's business location address is:

301 RODDY RD
SALEM, IL
ZIP 62881-836
Phone: (618) 548-0353

The provider's authorized official is Georgia Miller .
The authorized official title is Ceo and has the following contact phone number (618) 548-4561.

The CLIA number assigned to this NPI record is 14D1032094 - intermediate care facility for mentally retarded with a certificate type of Certificate of Waiver.

The enumeration date for this NPI number is 4/20/2007 and was last updated on 8/22/2020.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1315P00000XIntermediate Care Facility, Intellectual Disabilities0036004ILLINOISYes

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

No. Other Provider Identifier Other Provider Identifier Type Other Provider Identifier State Other Provider Identifier Issuer
114G242MEDICAIDILLINOIS

What is NPI?

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This page was last updated on: 3/30/2025

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