Organization
CHAMPAIGN RESIDENTIAL SERVICES, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. THAN JOHNSON (CHIEF EXECUTIVE OFFICER)
(937) 653-1320
Entity
Organization
Contact information
Practice address
1150 SCIOTO ST, SUITE 100, URBANA, OH 43078-2289
(937) 653-1320
(937) 653-1321
Mailing address
PO BOX 29, URBANA, OH 43078-0029
(937) 653-1320
(937) 653-1321
Taxonomy
Speciality
Code
Description
License number
State
320600000X
Intellectual and/or Developmental Disabilities Residential Treatment Facility
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0850637
—
OH
01
—
1100114
WAIVER BILLING PROVIDER #
OH
Enumeration date
01/24/2007
Last updated
08/22/2020
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