1295723500 NPI number — RESIDENTIAL ALTERNATIVES OF ILLINOIS, INC

Table of content: (NPI 1295723500)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295723500 NPI number — RESIDENTIAL ALTERNATIVES OF ILLINOIS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RESIDENTIAL ALTERNATIVES OF ILLINOIS, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CORALVILLE MANOR LLC , WINDMILL MANOR
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295723500
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2332 LIBERTY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORALVILLE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52241-2771
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-545-7390
Provider Business Mailing Address Fax Number:
319-545-7393

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2332 LIBERTY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORALVILLE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52241-2771
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-545-7390
Provider Business Practice Location Address Fax Number:
319-545-7393
Provider Enumeration Date:
10/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
309-343-1550

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  165545 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0809673 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 65545 . This is a "BLUE CROSS BLUE SHEILD #" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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