Provider Demographics
NPI:1790718781
Name:ADDUS HEALTHCARE (IDAHO), INC.
Entity Type:Organization
Organization Name:ADDUS HEALTHCARE (IDAHO), INC.
Other - Org Name:A FULL LIFE HEALTH CARE INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:NATIONAL CONTRACTS
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:KUMARICH
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MS, MBA
Authorized Official - Phone:847-303-5300
Mailing Address - Street 1:2401 S PLUM GROVE RD
Mailing Address - Street 2:
Mailing Address - City:PALATINE
Mailing Address - State:IL
Mailing Address - Zip Code:60067-7486
Mailing Address - Country:US
Mailing Address - Phone:847-303-5300
Mailing Address - Fax:847-303-5435
Practice Address - Street 1:233 E LOCUST AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-5748
Practice Address - Country:US
Practice Address - Phone:208-765-8016
Practice Address - Fax:208-765-0690
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADDUS HEALTHCARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-10
Last Update Date:2010-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDHH229251E00000X
IDHH-229251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807484500Medicaid
ID807484500Medicaid