Provider Demographics
NPI:1073643953
Name:RESIDENTIAL HORIZONS INC.
Entity Type:Organization
Organization Name:RESIDENTIAL HORIZONS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BRACKENBUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-287-1484
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:PANAMA
Mailing Address - State:IL
Mailing Address - Zip Code:62077-0640
Mailing Address - Country:US
Mailing Address - Phone:217-287-1484
Mailing Address - Fax:217-287-1010
Practice Address - Street 1:815 E VINE ST
Practice Address - Street 2:
Practice Address - City:TAYLORVILLE
Practice Address - State:IL
Practice Address - Zip Code:62568-1932
Practice Address - Country:US
Practice Address - Phone:217-287-1484
Practice Address - Fax:217-287-1010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0040766315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid