MEDICARE: ROSECRANCE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center	A-601-0036-A	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356709034
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROSECRANCE, INC.

Provider Business Mailing Address
First Line	:	1021 N MULFORD RD
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61107-3877
Country	:	US
Telephone Number	:	815-391-1000
Fax Number	:

Provider Business Practice Location Address
First Line	:	422 TRACY CT
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-6288
Country	:	US
Telephone Number	:	815-391-1000
Fax Number	:	815-316-4726

Authorized Official
Title or Position	:	CEO/PRESIDENT
Name	:	PHILIP EATON
Credential	:
Telephone Number	:	815-387-5600

Provider Enumeration Date	:	02/09/2016
Last Update Date	:	02/09/2016

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