Healthcare Provider Details

I. General information

NPI: 1629426002
Provider Name (Legal Business Name): ROSECRANCE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2016
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 N WALNUT ST
CHAMPAIGN IL
61820
US

IV. Provider business mailing address

1021 N MULFORD RD
ROCKFORD IL
61107-3877
US

V. Phone/Fax

Practice location:
  • Phone: 815-391-1000
  • Fax: 815-316-4726
Mailing address:
  • Phone: 815-391-1000
  • Fax: 815-316-4726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PHIL EATON
Title or Position: CEO / PRESIDENT
Credential: MBS
Phone: 815-391-1000