Provider Demographics
NPI:1992295984
Name:PENALI MANOR LLC
Entity type:Organization
Organization Name:PENALI MANOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:
Authorized Official - Last Name:NYALITA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:302-530-9489
Mailing Address - Street 1:8023 S 51ST DR
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-2840
Mailing Address - Country:US
Mailing Address - Phone:302-898-6406
Mailing Address - Fax:
Practice Address - Street 1:8023 S 51ST DR
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339-2840
Practice Address - Country:US
Practice Address - Phone:480-207-1272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH5417320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities