Provider Demographics
NPI:1649662495
Name:PEDIATRIC ADVANCED LIFE SERVICES HOME HEALTH LLC
Entity type:Organization
Organization Name:PEDIATRIC ADVANCED LIFE SERVICES HOME HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-307-8607
Mailing Address - Street 1:3640 W WACO DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710
Mailing Address - Country:US
Mailing Address - Phone:254-307-8607
Mailing Address - Fax:254-765-2501
Practice Address - Street 1:3640 W WACO DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710
Practice Address - Country:US
Practice Address - Phone:254-307-8607
Practice Address - Fax:254-765-2501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-02
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251G00000XAgenciesHospice Care, Community Based
No385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child