Provider Demographics
NPI:1962671701
Name:ROSECRANCE, INC.
Entity Type:Organization
Organization Name:ROSECRANCE, INC.
Other - Org Name:ROSECRANCE GREENDALE HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:W
Authorized Official - Last Name:EATON
Authorized Official - Suffix:
Authorized Official - Credentials:MASTERS IN SCIENCE
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:815-391-1000
Mailing Address - Fax:815-391-5040
Practice Address - Street 1:3522 GREEN DALE DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61109-1575
Practice Address - Country:US
Practice Address - Phone:815-391-5095
Practice Address - Fax:815-484-4750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-0601-0002-A324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILA-0601-0002-AMedicaid