Healthcare Provider Details

I. General information

NPI: 1710268008
Provider Name (Legal Business Name): ROSECRANCE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2011
Last Update Date: 12/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 BENTON ST
ROCKFORD IL
61107-4322
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:
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 Number04081
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. PHILLIP EATON
Title or Position: CEO / PRESIDENT
Credential:
Phone: 815-391-1000