Provider Demographics
NPI:1417303603
Name:PEDIALAC NURSING SERVICES LLC
Entity Type:Organization
Organization Name:PEDIALAC NURSING SERVICES LLC
Other - Org Name:PEDIALAC NURSING SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINSTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:AMA
Authorized Official - Last Name:CLARKE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:540-737-4010
Mailing Address - Street 1:1127 INTERNATIONAL PKWY STE 220
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBRG
Mailing Address - State:VA
Mailing Address - Zip Code:22406-1142
Mailing Address - Country:US
Mailing Address - Phone:540-737-4010
Mailing Address - Fax:540-737-4011
Practice Address - Street 1:1127 INTERNATIONAL PKWY STE 220
Practice Address - Street 2:
Practice Address - City:FREDERICKSBRG
Practice Address - State:VA
Practice Address - Zip Code:22406-1142
Practice Address - Country:US
Practice Address - Phone:540-737-4010
Practice Address - Fax:540-737-4011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-06
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAHCO 161444251E00000X
251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health