Provider Demographics
NPI:1689911554
Name:PENN RESIDENTIAL, INC.
Entity Type:Organization
Organization Name:PENN RESIDENTIAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:
Authorized Official - First Name:CLYDE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-635-0048
Mailing Address - Street 1:PO BOX C
Mailing Address - Street 2:
Mailing Address - City:NEW STANTON
Mailing Address - State:PA
Mailing Address - Zip Code:15672-0417
Mailing Address - Country:US
Mailing Address - Phone:724-635-0048
Mailing Address - Fax:724-635-0746
Practice Address - Street 1:PO BOX C
Practice Address - Street 2:
Practice Address - City:NEW STANTON
Practice Address - State:PA
Practice Address - Zip Code:15672-0417
Practice Address - Country:US
Practice Address - Phone:724-635-0048
Practice Address - Fax:724-635-0746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-11
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA444280322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102577794Medicaid