Basic Information
Provider Information | |||||||||
NPI: | 1144533654 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ADDUS HEALTHCARE (SOUTH CAROLINA), INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ADDUS HOMECARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2300 WARRENVILLE RD | ||||||||
Address2: | STE 100 | ||||||||
City: | DOWNERS GROVE | ||||||||
State: | IL | ||||||||
PostalCode: | 605151765 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6302963400 | ||||||||
FaxNumber: | 6304782713 | ||||||||
Practice Location | |||||||||
Address1: | 3294 ASHLEY PHOSPHATE RD STE F | ||||||||
Address2: | C | ||||||||
City: | N CHARLESTON | ||||||||
State: | SC | ||||||||
PostalCode: | 29418 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8662846331 | ||||||||
FaxNumber: | 8435690062 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/26/2010 | ||||||||
LastUpdateDate: | 12/04/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KUMARICH | ||||||||
AuthorizedOfficialFirstName: | DIANE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | NATIONAL CONTRACTS | ||||||||
AuthorizedOfficialTelephone: | 6302963400 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | RN, MS, MBA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X |   |   | Y |   | Agencies | Hospice Care, Community Based |   |
No ID Information.