Provider Demographics
NPI:1932508991
Name:FAMILY PEDIATRIC HOME CARE
Entity Type:Organization
Organization Name:FAMILY PEDIATRIC HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:MS
Authorized Official - First Name:KADIATU
Authorized Official - Middle Name:
Authorized Official - Last Name:KOROMA
Authorized Official - Suffix:
Authorized Official - Credentials:NURSING
Authorized Official - Phone:516-850-0643
Mailing Address - Street 1:100 TERRACE AVE
Mailing Address - Street 2:APT 555
Mailing Address - City:HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11550
Mailing Address - Country:US
Mailing Address - Phone:516-850-0643
Mailing Address - Fax:
Practice Address - Street 1:50 CLINTON STREET
Practice Address - Street 2:SUITE 601
Practice Address - City:HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11550-2314
Practice Address - Country:US
Practice Address - Phone:516-993-0485
Practice Address - Fax:516-993-1923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-15
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY309696-13140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric