Basic Information
| Provider Information | |||||||||
| NPI: | 1609128271 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADDUS HEALTHCARE (DELAWARE), INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ADDUS HOME CARE DELAWARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 WARRENVILLE RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | DOWNERS GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605151765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302963400 | ||||||||
| FaxNumber: | 6304872713 | ||||||||
| Practice Location | |||||||||
| Address1: | 1675 S STATE ST | ||||||||
| Address2: | ROOM A | ||||||||
| City: | DOVER | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199015140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3022337087 | ||||||||
| FaxNumber: | 3024244974 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2012 | ||||||||
| LastUpdateDate: | 06/17/2015 | ||||||||
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| 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 | 251F00000X | DE | N | Agencies | Home Infusion | 251C00000X | DE | N | Agencies | Day Training, Developmentally Disabled Services | 253J00000X | DE | N | Agencies | Foster Care Agency | 253Z00000X | Y | Agencies | In Home Supportive Care |
ID Information
| ID | Type | State | Issuer | Description | 519055 | 01 | DE | MEDICARE ID - TYPE UNSPECIFIED | OTHER | 761414 | 05 | DE | MEDICAID |