Provider Demographics
NPI:1316166382
Name:RESIDENTIAL OPTIONS
Entity type:Organization
Organization Name:RESIDENTIAL OPTIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:STAFSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-465-0044
Mailing Address - Street 1:56 CHOUTEAU TRACE PKWY
Mailing Address - Street 2:
Mailing Address - City:GRANITE CITY
Mailing Address - State:IL
Mailing Address - Zip Code:62040-6710
Mailing Address - Country:US
Mailing Address - Phone:618-797-2262
Mailing Address - Fax:618-797-2264
Practice Address - Street 1:56 CHOUTEAU TRACE PKWY
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-6710
Practice Address - Country:US
Practice Address - Phone:618-797-2262
Practice Address - Fax:618-797-2264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0036905320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6012793OtherPUBLIC HEALTH FACILITY ID
IL14G256Medicare ID - Type Unspecified