Basic Information
| Provider Information | |||||||||
| NPI: | 1861901043 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROSECRANCE INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1021 N MULFORD RD | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611073877 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153875600 | ||||||||
| FaxNumber: | 8153164726 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 LEE ST | ||||||||
| Address2: | |||||||||
| City: | DES PLAINES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600164539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153911000 | ||||||||
| FaxNumber: | 8153915040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2017 | ||||||||
| LastUpdateDate: | 04/24/2018 | ||||||||
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| AuthorizedOfficialLastName: | EATON | ||||||||
| AuthorizedOfficialFirstName: | PHILIP | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8153875600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | A-0601-0052-A | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | A-0601-0052-A | 01 | IL | IL STATE LICENSE | OTHER |