Provider Demographics
NPI:1922358373
Name:CRUSADERS CENTRAL CLINIC ASSOCIATION
Entity Type:Organization
Organization Name:CRUSADERS CENTRAL CLINIC ASSOCIATION
Other - Org Name:ROSECRANCE WARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-490-1737
Mailing Address - Street 1:1200 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61102-2112
Mailing Address - Country:US
Mailing Address - Phone:815-490-1600
Mailing Address - Fax:815-490-1845
Practice Address - Street 1:2704 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61103-3112
Practice Address - Country:US
Practice Address - Phone:815-490-1600
Practice Address - Fax:815-490-1845
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CRUSADERS CENTRAL CLINIC ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-09-13
Last Update Date:2023-08-08
Deactivation Date:2022-02-25
Deactivation Code:
Reactivation Date:2023-08-08
Provider Licenses
StateLicense IDTaxonomies
IL261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)