Basic Information
| Provider Information | |||||||||
| NPI: | 1497718951 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROFESSIONAL RELIABLE NURSING SERVICE INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ADDUS HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2300 WARRENVILLE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | DOWNERS GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605151717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302963591 | ||||||||
| FaxNumber: | 6304872713 | ||||||||
| Practice Location | |||||||||
| Address1: | 3501 COFFEE RD STE 3 | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953551343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095268451 | ||||||||
| FaxNumber: | 2095746116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2006 | ||||||||
| LastUpdateDate: | 10/07/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | DARBY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EVP CHIEF STRATEGY OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6302963591 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ADDUS HEALTHCARE, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251C00000X | N | Agencies | Day Training, Developmentally Disabled Services | 251E00000X | 100000005 | CA | N | Agencies | Home Health | 251F00000X | N | Agencies | Home Infusion | 251J00000X | N | Agencies | Nursing Care | 253Z00000X | Y | Agencies | In Home Supportive Care |
ID Information
| ID | Type | State | Issuer | Description | HHA57272F | 05 | CA | MEDICAID |