Basic Information
| Provider Information | |||||||||
| NPI: | 1154490985 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROSECRANCE NEW LIFE OUTPATIENT CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NEW OUTPATIENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1021 N MULFORD RD | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611073877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153911000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2322 E KIMBERLY RD STE 200 PAUL REVERE SQ | ||||||||
| Address2: | |||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528073042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633550055 | ||||||||
| FaxNumber: | 5633550101 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 01/23/2020 | ||||||||
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| AuthorizedOfficialLastName: | SCHUSTER | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT/CFO | ||||||||
| AuthorizedOfficialTelephone: | 8153875642 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ROSECRANCE HEALTH NETWORK | ||||||||
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| NPICertificationDate: | 01/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QR0405X | 1231 | IA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.