Basic Information
| Provider Information | |||||||||
| NPI: | 1437507811 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROSECRANCE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1021 N MULFORD RD | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611073877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153911000 | ||||||||
| FaxNumber: | 8153164726 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 N WALNUT ST | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618203055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153911000 | ||||||||
| FaxNumber: | 8153164726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2016 | ||||||||
| LastUpdateDate: | 12/13/2016 | ||||||||
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| AuthorizedOfficialLastName: | EATON | ||||||||
| AuthorizedOfficialFirstName: | PHIL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO / PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8153911000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 261QR0405X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
ID Information
| ID | Type | State | Issuer | Description | 1801-0003 | 05 | IL | MEDICAID |