Provider Demographics
NPI:1134311277
Name:RITA ARMBRUST
Entity Type:Organization
Organization Name:RITA ARMBRUST
Other - Org Name:RANDOLPH HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RITA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ARMBRUST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-548-0309
Mailing Address - Street 1:PO BOX 871
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-0871
Mailing Address - Country:US
Mailing Address - Phone:618-548-0309
Mailing Address - Fax:618-548-3720
Practice Address - Street 1:404 S 1ST ST
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-0279
Practice Address - Country:US
Practice Address - Phone:618-283-0689
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-13
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0031633315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========002Medicaid