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General NPI Number Information
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NPI Number | 1609069335
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Entity Type | Organization
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Legal Business Name | RAVE RESIDENTIAL SERVICES, INC
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Dates
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Enumeration Date | 08/27/2007
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Last Update Date | 04/20/2008
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Provider Practice Location Address
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Address Line | 1430 STATE ROUTE 127 S
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City | JONESBORO
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State | IL
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Zip | 62952-2489
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Country | US
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Telephone | 618-833-8033
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Fax | 618-833-8035
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Provider Business Mailing Address
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Address Line | 1390 STATE ROUTE 127 S
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City | JONESBORO
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State | IL
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Zip | 62952-2488
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Country | US
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Telephone | 618-833-5377
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Fax | 618-833-8217
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. GARY L GRIFFITH
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Credential | L.N.H.A.
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Telephone | 618-833-5344
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | 0040970
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License Number State | IL
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