Provider Demographics
NPI:1932371382
Name:COMMUNITY LIVING OPTIONS INC
Entity Type:Organization
Organization Name:COMMUNITY LIVING OPTIONS INC
Other - Org Name:EDWARDSVILLE TERRACE
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 1:808 SOUTHWEST PLACE
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-3661
Practice Address - Country:US
Practice Address - Phone:618-656-6161
Practice Address - Fax:618-656-6286
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY LIVING OPTIONS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-26
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL38844315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========009Medicaid