Provider Demographics
NPI:1700996972
Name:RESIDENTIAL ALTERNATIVES OF ILLINOIS, INC.
Entity Type:Organization
Organization Name:RESIDENTIAL ALTERNATIVES OF ILLINOIS, INC.
Other - Org Name:MANOR COURT OF PEORIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
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 1:6906 N STALWORTH DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-9488
Mailing Address - Country:US
Mailing Address - Phone:309-693-1400
Mailing Address - Fax:309-683-3561
Practice Address - Street 1:6900 N STALWORTH DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-9488
Practice Address - Country:US
Practice Address - Phone:309-693-1400
Practice Address - Fax:309-683-3561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0047068314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========012Medicaid
146108Medicare Oscar/Certification