Organization
RESIDENTIAL OPTIONS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SUSAN L STAFSTROM (ACCOUNTING MANAGER)
(618) 465-0044
Entity
Organization
Contact information
Practice address
56 CHOUTEAU TRACE PKWY, GRANITE CITY, IL 62040-6710
(618) 797-2262
(618) 797-2264
Mailing address
56 CHOUTEAU TRACE PKWY, GRANITE CITY, IL 62040-6710
(618) 797-2262
(618) 797-2264
Taxonomy
Speciality
Code
Description
License number
State
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
0036905
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
6012793
PUBLIC HEALTH FACILITY ID
IL
Enumeration date
04/25/2007
Last updated
08/22/2020
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