Basic Information
Provider Information | |||||||||
NPI: | 1770704777 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ADDUS HEALTHCARE (IDAHO), 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: | 1037A 21ST ST | ||||||||
Address2: |   | ||||||||
City: | LEWISTON | ||||||||
State: | ID | ||||||||
PostalCode: | 835013415 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2087468881 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/01/2007 | ||||||||
LastUpdateDate: | 01/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ANDERSON | ||||||||
AuthorizedOfficialFirstName: | DARBY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EVP STRATEGY OFFICER | ||||||||
AuthorizedOfficialTelephone: | 6302963591 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ADDUS HEALTHCARE, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/28/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251J00000X |   |   | Y |   | Agencies | Nursing Care |   |
ID Information
ID | Type | State | Issuer | Description | 805787300 | 01 | ID | HAYDEN - PDN | OTHER |