Basic Information
Provider Information | |||||||||
NPI: | 1124043039 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRAC HOLDINGS, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2300 WARRENVILLE RD., STE 100 | ||||||||
Address2: |   | ||||||||
City: | DOWNERS GROVE | ||||||||
State: | IL | ||||||||
PostalCode: | 605151765 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6302963530 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4615 N 1ST AVE | ||||||||
Address2: |   | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857185608 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5208887566 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2006 | ||||||||
LastUpdateDate: | 04/16/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KUMARICH | ||||||||
AuthorizedOfficialFirstName: | DIANE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP NATIONAL CONTRACTS | ||||||||
AuthorizedOfficialTelephone: | 6302963400 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ADDUS HEALTHCARE INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | RN, MS, MBA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | HHA1269 | AZ | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | 961872 | 05 | AZ |   | MEDICAID |