Basic Information
| Provider Information | |||||||||
| NPI: | 1740601236 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADDUS HEALTHCARE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ADDUS EVERGREEN CLUB | ||||||||
| 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: | 88 NORTHPORT DR | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620025940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184339180 | ||||||||
| FaxNumber: | 6184339182 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2013 | ||||||||
| LastUpdateDate: | 06/17/2015 | ||||||||
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| AuthorizedOfficialLastName: | KUMARICH | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | NATIONAL CONTRACTS | ||||||||
| AuthorizedOfficialTelephone: | 6302963400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | RN, MS, MBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253Z00000X | Y | Agencies | In Home Supportive Care |
No ID Information.