MEDICARE: RESIDENTIAL OPTIONS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	0036814	IL
2	315P00000X	Intellectual Disabilities Intermediate Care Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6012744	OTHER	IL	PUBLIC HEALTH FACILITY ID

General Provider Information

NPI Number	:	1770702763
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RESIDENTIAL OPTIONS, INC.

Provider Business Mailing Address
First Line	:	4710 PIERCE LN
Second Line	:
City	:	GODFREY
State	:	IL
Zip	:	62035-4151
Country	:	US
Telephone Number	:	618-466-5255
Fax Number	:	618-466-7450

Provider Business Practice Location Address
First Line	:	4710 PIERCE LN
Second Line	:
City	:	GODFREY
State	:	IL
Zip	:	62035-4151
Country	:	US
Telephone Number	:	618-466-5255
Fax Number	:	618-466-7450

Authorized Official
Title or Position	:	VP
Name	:	DIANE TEBBE
Credential	:
Telephone Number	:	618-465-0044

Provider Enumeration Date	:	04/25/2007
Last Update Date	:	11/01/2017

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Directions to “RESIDENTIAL OPTIONS, INC. ” Practice Location

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