Provider Demographics
NPI:1154490985
Name:ROSECRANCE NEW LIFE OUTPATIENT CENTER
Entity Type:Organization
Organization Name:ROSECRANCE NEW LIFE OUTPATIENT CENTER
Other - Org Name:NEW OUTPATIENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT/CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHUSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-387-5642
Mailing Address - Street 1:1021 N MULFORD RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-3877
Mailing Address - Country:US
Mailing Address - Phone:815-391-1000
Mailing Address - Fax:
Practice Address - Street 1:2322 E KIMBERLY RD STE 200 PAUL REVERE SQ
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-3042
Practice Address - Country:US
Practice Address - Phone:563-355-0055
Practice Address - Fax:563-355-0101
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROSECRANCE HEALTH NETWORK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-07
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X
IA1231261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA=========Medicaid