Healthcare Provider Details

I. General information

NPI: 1063891646
Provider Name (Legal Business Name): ROSECRANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2015
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3701 N ASHLAND AVE
CHICAGO IL
60613-3601
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 Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

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