Provider Demographics
NPI:1821296567
Name:PENTA C. ENTERPRICES, INC.
Entity Type:Organization
Organization Name:PENTA C. ENTERPRICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-243-1992
Mailing Address - Street 1:3009 RAINBOW DR
Mailing Address - Street 2:142
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-1680
Mailing Address - Country:US
Mailing Address - Phone:404-243-1992
Mailing Address - Fax:404-243-4903
Practice Address - Street 1:3009 RAINBOW DR
Practice Address - Street 2:142
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-1680
Practice Address - Country:US
Practice Address - Phone:404-243-1992
Practice Address - Fax:404-243-4903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YM0800X101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty