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

General Provider Information

NPI Number	:	1366199200
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	:	61107-3874
Country	:	US
Telephone Number	:	815-387-5623
Fax Number	:

Provider Business Practice Location Address
First Line	:	1631 S GALENA AVE
Second Line	:
City	:	FREEPORT
State	:	IL
Zip	:	61032-2517
Country	:	US
Telephone Number	:	815-391-1000
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DAVE GOMEL
Credential	:
Telephone Number	:	815-391-1000

Provider Enumeration Date	:	03/09/2022
Last Update Date	:	06/08/2022

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Directions to “ROSECRANCE INC ” Practice Location

Language	Start Address	Practice Location

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