Basic Information
Provider Information | |||||||||
NPI: | 1558784231 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ADDUS HEALTHCARE, 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 STE 100 | ||||||||
Address2: |   | ||||||||
City: | DOWNERS GROVE | ||||||||
State: | IL | ||||||||
PostalCode: | 605151717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6302963591 | ||||||||
FaxNumber: | 6304872713 | ||||||||
Practice Location | |||||||||
Address1: | 5802 SUMMITVIEW AVE STE 190 | ||||||||
Address2: |   | ||||||||
City: | YAKIMA | ||||||||
State: | WA | ||||||||
PostalCode: | 989083073 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5099655126 | ||||||||
FaxNumber: | 5099655129 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/30/2014 | ||||||||
LastUpdateDate: | 12/18/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ANDERSON | ||||||||
AuthorizedOfficialFirstName: | DARBY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EVP, CHIEF STRATEGY OFFICER | ||||||||
AuthorizedOfficialTelephone: | 6302963591 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ADDUS HOMECARE CORPORATION | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/18/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253Z00000X |   |   | Y |   | Agencies | In Home Supportive Care |   |
No ID Information.