Provider Demographics
NPI:1770569972
Name:ROSECRANCE INC
Entity type:Organization
Organization Name:ROSECRANCE INC
Other - Org Name:
Other - Org Type:
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:MASTER OF SCIENCE
Authorized Official - Phone:815-391-0100
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:815-391-0100
Mailing Address - Fax:815-391-5040
Practice Address - Street 1:810 E STATE ST STE 200
Practice Address - Street 2:RIVER DISTRICT CLINIC
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-1001
Practice Address - Country:US
Practice Address - Phone:815-391-1000
Practice Address - Fax:815-967-8724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-20
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========008Medicaid