Basic Information
| Provider Information | |||||||||
| NPI: | 1285690842 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FORT SMITH HOME HEALTH AGENCY INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CARE NETWORK OF FT SMITH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 S PLUM GROVE RD | ||||||||
| Address2: | |||||||||
| City: | PALATINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473035300 | ||||||||
| FaxNumber: | 8473035376 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 N 12TH STREET | ||||||||
| Address2: | |||||||||
| City: | FT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794947273 | ||||||||
| FaxNumber: | 4794947387 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2006 | ||||||||
| LastUpdateDate: | 06/18/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| 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 | AR4235 | AR | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 137746514 | 05 | AR | MEDICAID | 138510757 | 05 | AR | MEDICAID | 137747738 | 05 | AR | MEDICAID | 137748732 | 05 | AR | MEDICAID | 138500750 | 05 | AR | MEDICAID | 138509752 | 05 | AR | MEDICAID | 139075742 | 05 | AR | MEDICAID | 141491765 | 05 | AR | MEDICAID |