Basic Information
Provider Information | |||||||||
NPI: | 1689018673 | ||||||||
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 | ||||||||
Address2: | SUITE 100 | ||||||||
City: | DOWNERS GROVE | ||||||||
State: | IL | ||||||||
PostalCode: | 605151765 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6302963400 | ||||||||
FaxNumber: | 6304872713 | ||||||||
Practice Location | |||||||||
Address1: | 201 S 20TH ST | ||||||||
Address2: | SUITE 11 | ||||||||
City: | ROGERS | ||||||||
State: | AR | ||||||||
PostalCode: | 727581104 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4798773300 | ||||||||
FaxNumber: | 8772247103 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/22/2013 | ||||||||
LastUpdateDate: | 11/10/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
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 | 251E00000X | AR4954 | AR | N |   | Agencies | Home Health |   | 253Z00000X | AR4954 | AR | Y |   | Agencies | In Home Supportive Care |   |
ID Information
ID | Type | State | Issuer | Description | 197340797 | 05 | AR |   | MEDICAID | 197338796 | 05 | AR |   | MEDICAID | 200411732 MAPC | 05 | AR |   | MEDICAID | 197342752 | 05 | AR |   | MEDICAID | 197341757 | 05 | AR |   | MEDICAID |