Healthcare Provider Details

I. General information

NPI: 1104047174
Provider Name (Legal Business Name): RESIDENTIAL OPTIONS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/21/2022
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4617 WONDERLAND DR
ALTON IL
62002-7309
US

IV. Provider business mailing address

4617 WONDERLAND DR
ALTON IL
62002-7309
US

V. Phone/Fax

Practice location:
  • Phone: 618-465-8845
  • Fax: 618-463-4890
Mailing address:
  • Phone: 618-465-8845
  • Fax: 618-463-4890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number0039123
License Number StateIL

VIII. Authorized Official

Name: DIANE TEBBE
Title or Position: VP
Credential:
Phone: 618-465-0044