Provider Demographics
NPI:1023368529
Name:SWEET PEAS'S PEDI CARE, INC
Entity Type:Organization
Organization Name:SWEET PEAS'S PEDI CARE, INC
Other - Org Name:SWEET PEAS'S PEDI CARE, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:R
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-824-1833
Mailing Address - Street 1:6326 SOVEREIGN ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-5139
Mailing Address - Country:US
Mailing Address - Phone:210-824-1833
Mailing Address - Fax:210-824-1835
Practice Address - Street 1:6326 SOVEREIGN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-5139
Practice Address - Country:US
Practice Address - Phone:210-824-1833
Practice Address - Fax:210-824-1835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-12
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX015902251E00000X, 251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX340528401Medicaid