Provider Demographics
NPI:1811166754
Name:ROSECRANCE, INC.
Entity type:Organization
Organization Name:ROSECRANCE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PHIL
Authorized Official - Middle Name:W
Authorized Official - Last Name:EATON
Authorized Official - Suffix:
Authorized Official - Credentials:MASTER OF 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:815-316-4726
Practice Address - Street 1:1601 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5317
Practice Address - Country:US
Practice Address - Phone:815-391-1000
Practice Address - Fax:815-316-4726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-0601-0020-A324500000X
324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILA-0601-0020-AMedicaid
IL=========014Medicaid