Provider Demographics
NPI:1609014224
Name:CHAMPAIGN RESIDENTIAL SERVICES, INC.
Entity Type:Organization
Organization Name:CHAMPAIGN RESIDENTIAL SERVICES, INC.
Other - Org Name:PAUL LOFFING RAINBOW UNIT
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:THAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-653-1320
Mailing Address - Street 1:P.O. BOX 29
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:OH
Mailing Address - Zip Code:43078-0029
Mailing Address - Country:US
Mailing Address - Phone:937-653-1320
Mailing Address - Fax:937-653-1321
Practice Address - Street 1:2380 ST. RT. 68 SOUTH
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:OH
Practice Address - Zip Code:43078
Practice Address - Country:US
Practice Address - Phone:937-653-1320
Practice Address - Fax:937-653-1321
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHAMPAIGN RESIDENTIAL SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-04
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2784018Medicaid
OH2784018Medicaid