Provider Demographics
NPI:1245696434
Name:123 PEDIATRIC HOME HEALTHCARE CORPORATION
Entity type:Organization
Organization Name:123 PEDIATRIC HOME HEALTHCARE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:JUANITA
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:412-377-9102
Mailing Address - Street 1:6309 HALLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:PA
Mailing Address - Zip Code:15147-2526
Mailing Address - Country:US
Mailing Address - Phone:412-377-9102
Mailing Address - Fax:
Practice Address - Street 1:6309 HALLWOOD DR
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:PA
Practice Address - Zip Code:15147-2526
Practice Address - Country:US
Practice Address - Phone:412-377-9102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-05
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0170871041C0700X
PARN620599163WG0000X, 163WH0200X, 163WI0500X, 163WP0200X, 163WP0218X, 163WW0000X, 163WX0200X, 251J00000X
PA06400501251B00000X, 251F00000X, 251J00000X, 251E00000X
PA30153601253Z00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Multi-Specialty
No163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Multi-Specialty
No163WI0500XNursing Service ProvidersRegistered NurseInfusion TherapyGroup - Multi-Specialty
No163WP0200XNursing Service ProvidersRegistered NursePediatricsGroup - Multi-Specialty
No163WP0218XNursing Service ProvidersRegistered NursePediatric OncologyGroup - Multi-Specialty
No163WW0000XNursing Service ProvidersRegistered NurseWound CareGroup - Multi-Specialty
No163WX0200XNursing Service ProvidersRegistered NurseOncologyGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No251F00000XAgenciesHome Infusion
No251J00000XAgenciesNursing Care
No253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1030784200001OtherSTATE OF PA DHS OFFICE OF INTELLECTUAL DISABILITIES PROVIDER NUMBER
PA06400501OtherSTATE OF PENNSYLVANIA
PA30153601OtherSTATE OF PENNSYLVANIA
PA1030784200002OtherSTATE OF PA DHS OFFICE OF LONG TERM LIVING PROVIDER NUMBER