Provider Demographics
NPI:1568095719
Name:PEDIALIFE OF LA, L.L.C.
Entity Type:Organization
Organization Name:PEDIALIFE OF LA, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DEVELLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:COLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, RN
Authorized Official - Phone:817-296-5938
Mailing Address - Street 1:2427 RIVERSIDE DR.
Mailing Address - Street 2:
Mailing Address - City:PORT ALLEN
Mailing Address - State:LA
Mailing Address - Zip Code:70767-6009
Mailing Address - Country:US
Mailing Address - Phone:817-296-5938
Mailing Address - Fax:817-563-5435
Practice Address - Street 1:2427 RIVERSIDE DR.
Practice Address - Street 2:
Practice Address - City:PORT ALLEN
Practice Address - State:LA
Practice Address - Zip Code:70767-6009
Practice Address - Country:US
Practice Address - Phone:817-296-5938
Practice Address - Fax:817-563-5435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-17
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health