Provider Demographics
NPI:1578082020
Name:ROSECRANCE INC.
Entity Type:Organization
Organization Name:ROSECRANCE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF PAYER RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:PRIMM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-391-1000
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:815-387-5600
Mailing Address - Fax:815-316-4726
Practice Address - Street 1:5440 N CUMBERLAND AVE STE 165
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60656-4708
Practice Address - Country:US
Practice Address - Phone:815-391-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-15
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-0601-0052-A261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILA-0601-0052-AOtherDASA LICENSE