1134178098 NPI number — PEDIATRIC HOME CARE, INC.

Table of content: (NPI 1134178098)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134178098 NPI number — PEDIATRIC HOME CARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC HOME CARE, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
AVEANNA HEALTHCARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134178098
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 INTERSTATE NORTH PKWY SE STE 1600
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30339-5047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
470-464-8000
Provider Business Mailing Address Fax Number:
770-248-8192

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1120 NORTH MULLAN ROAD
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
SPOKANE VALLEY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99206-4074
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-368-9252
Provider Business Practice Location Address Fax Number:
509-368-9594
Provider Enumeration Date:
05/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DRAKE
Authorized Official First Name:
SHANNON
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF LEGAL OFFICER
Authorized Official Telephone Number:
470-464-8000

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  PF00057031 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X , with the licence number: 00000344 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X , with the licence number: PF00057031 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336H0001X , with the licence number: PF00057031 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 806198700 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0213350 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6025159 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7331622 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 806189200 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9051780 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0561646 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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