Provider Demographics
NPI:1225296858
Name:RESIDENTIAL ALTERNATIVES OF ILLINOIS INC
Entity Type:Organization
Organization Name:RESIDENTIAL ALTERNATIVES OF ILLINOIS INC
Other - Org Name:HAWTHORNE INN OF FREEPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED AGENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:309-343-1550
Mailing Address - Street 1:285 SOUTH FARNHAM STREET
Mailing Address - Street 2:
Mailing Address - City:GALESBURG
Mailing Address - State:IL
Mailing Address - Zip Code:61401-5323
Mailing Address - Country:US
Mailing Address - Phone:309-343-1550
Mailing Address - Fax:309-343-6318
Practice Address - Street 1:2140 WEST NAVAJO DRIVE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-7803
Practice Address - Country:US
Practice Address - Phone:815-235-0778
Practice Address - Fax:815-232-3407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========011Medicaid