=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568459709
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROSECRANCE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2005
-----------------------------------------------------
Last Update Date | 04/26/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3815 HARRISON AVE OUTPATIENT
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61108-7631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-391-0100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3815 HARRISON AVE
-----------------------------------------------------
City | ROCKFORD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61108-7631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-391-0100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT CEO
-----------------------------------------------------
Name | MR. PHILIP W EATON
-----------------------------------------------------
Credential | MASTER OF SCIENCE
-----------------------------------------------------
Telephone | 815-391-0100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------