Provider Demographics
NPI:1871964650
Name:CHAMPAIGN RESIDENTIAL SERVICES INC
Entity type:Organization
Organization Name:CHAMPAIGN RESIDENTIAL SERVICES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:A
Authorized Official - Last Name:DELONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-653-1320
Mailing Address - Street 1:1150 SCIOTO ST
Mailing Address - Street 2:PO BOX 29
Mailing Address - City:URBANA
Mailing Address - State:OH
Mailing Address - Zip Code:43078-2289
Mailing Address - Country:US
Mailing Address - Phone:937-653-1320
Mailing Address - Fax:937-653-1321
Practice Address - Street 1:12 ORCHARD PARK
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883
Practice Address - Country:US
Practice Address - Phone:937-653-1320
Practice Address - Fax:937-653-1321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-19
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities