Basic Information
| Provider Information | |||||||||
| NPI: | 1356758171 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADDUS HEALTHCARE (IDAHO), INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ADDUS HOMECARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 WARRENVILLE RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | DOWNERS GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605151702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302963400 | ||||||||
| FaxNumber: | 6304872713 | ||||||||
| Practice Location | |||||||||
| Address1: | 164 RIVER VISTA PL | ||||||||
| Address2: | |||||||||
| City: | TWIN FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 833013056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087339100 | ||||||||
| FaxNumber: | 2087332005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2014 | ||||||||
| LastUpdateDate: | 06/24/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | DARBY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EVP, CHIEF STRATEGY OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6302963591 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ADDUS HEALTH CARE INC | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253Z00000X | Y | Agencies | In Home Supportive Care |
ID Information
| ID | Type | State | Issuer | Description | 806491201 | 05 | ID | MEDICAID | 806582500 | 05 | ID | MEDICAID | 806491602 | 05 | ID | MEDICAID | 806510001 | 05 | ID | MEDICAID |