Healthcare Provider Details

I. General information

NPI: 1124449731
Provider Name (Legal Business Name): ROSECRANCE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2013
Last Update Date: 09/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

422 TRACY COURT
CRYSTAL LAKE IL
60014
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 Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

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