Basic Information
| Provider Information | |||||||||
| NPI: | 1790718781 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADDUS HEALTHCARE (IDAHO), INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | A FULL LIFE HEALTH CARE INC. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 S PLUM GROVE RD | ||||||||
| Address2: | |||||||||
| City: | PALATINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600677486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473035300 | ||||||||
| FaxNumber: | 8473035435 | ||||||||
| Practice Location | |||||||||
| Address1: | 233 E LOCUST AVE | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838145748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087658016 | ||||||||
| FaxNumber: | 2087650690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 05/26/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KUMARICH | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | NATIONAL CONTRACTS | ||||||||
| AuthorizedOfficialTelephone: | 8473035300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ADDUS HEALTHCARE, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN, MS, MBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | HH229 | ID | N | Agencies | Home Health | 251E00000X | HH-229 | ID | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 807484500 | 05 | ID | MEDICAID |