Provider Demographics
NPI:1245423979
Name:RAVE RESIDENTIAL SERVICES, INC.
Entity Type:Organization
Organization Name:RAVE RESIDENTIAL SERVICES, INC.
Other - Org Name:PEACHTREE ESTATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:GRIFFITH
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:618-833-5344
Mailing Address - Street 1:1390 STATE ROUTE 127 S
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62952-2488
Mailing Address - Country:US
Mailing Address - Phone:618-833-5344
Mailing Address - Fax:618-833-8217
Practice Address - Street 1:1370 STATE ROUTE 127 S
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:IL
Practice Address - Zip Code:62952-2488
Practice Address - Country:US
Practice Address - Phone:618-833-3235
Practice Address - Fax:618-833-3237
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RAVE RESIDENTIAL SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-27
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0040626315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid