Healthcare Provider Details

I. General information

NPI: 1770569972
Provider Name (Legal Business Name): ROSECRANCE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2005
Last Update Date: 07/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 E STATE ST STE 200 RIVER DISTRICT CLINIC
ROCKFORD IL
61104-1001
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: 815-967-8724
Mailing address:
  • Phone: 815-391-0100
  • Fax: 815-391-5040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. PHILIP W EATON
Title or Position: PRESIDENT CEO
Credential: MASTER OF SCIENCE
Phone: 815-391-0100