Basic Information
| Provider Information | |||||||||
| NPI: | 1659397016 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRAC HOLDINGS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | ARCADIA HOME CARE & STAFFING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2300 WARRENVILLE RD., STE 100 | ||||||||
| Address2: | |||||||||
| City: | DOWNERS GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605151765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302963530 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2600 AIRPORT RD STE A | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492021238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177960971 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 10/20/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 09/14/2021 | ||||||||
| NPIReactivationDate: | 10/20/2021 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ANDERSON | ||||||||
| AuthorizedOfficialFirstName: | DARBY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SVP CHIEF STRATEGY OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6302963400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ADDUS HEALTHCARE INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | J5039 | 01 | MI | BLUE CROSS | OTHER |