Healthcare Provider Details

I. General information

NPI: 1942306790
Provider Name (Legal Business Name): RESIDENTIAL CRF, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 09/06/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 UNIVERSITY AVE SUITE 500
LAS VEGAS NM
87701-4278
US

IV. Provider business mailing address

1117 N CENTRAL AVE
CONNERSVILLE IN
47331-2126
US

V. Phone/Fax

Practice location:
  • Phone: 505-425-5429
  • Fax: 505-425-5379
Mailing address:
  • Phone: 765-827-6996
  • Fax: 765-827-5809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number1835362
License Number StateIN

VIII. Authorized Official

Name: MS. KIM WRIGHT
Title or Position: ACCOUNTING ASSISTANT
Credential:
Phone: 765-827-6996