Basic Information
| Provider Information | |||||||||
| NPI: | 1720488604 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROSECRANCE INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ROSECRANCE WOODSTOCK HOUSE | ||||||||
| 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: | 8153164726 | ||||||||
| Practice Location | |||||||||
| Address1: | 876 PLEASANT ST | ||||||||
| Address2: | |||||||||
| City: | WOODSTOCK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600982245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153911000 | ||||||||
| FaxNumber: | 8153164726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2014 | ||||||||
| LastUpdateDate: | 04/26/2018 | ||||||||
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| AuthorizedOfficialLastName: | EATON | ||||||||
| AuthorizedOfficialFirstName: | PHILIP | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO / PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8153911000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | A-0601-0039-A | 05 | IL | MEDICAID |