Basic Information
| Provider Information | |||||||||
| NPI: | 1003879552 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADDUS HEALTHCARE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PREMIER HEALTH CONNECTION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2401 S PLUM GROVE RD | ||||||||
| Address2: | |||||||||
| City: | PALATINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473035300 | ||||||||
| FaxNumber: | 8473035376 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 SUTTER ST | ||||||||
| Address2: | STE 360 | ||||||||
| City: | CONCORD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9256714100 | ||||||||
| FaxNumber: | 9253562889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2006 | ||||||||
| LastUpdateDate: | 09/28/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KUMARICH | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | NATIONAL CONTRACTS | ||||||||
| AuthorizedOfficialTelephone: | 8473035300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN, MS, MBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251F00000X | N | Agencies | Home Infusion | 251J00000X | N | Agencies | Nursing Care | 251C00000X | N | Agencies | Day Training, Developmentally Disabled Services | 251E00000X | 020000226 | CA | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | HHA70123G | 05 | CA | MEDICAID |