Provider Demographics
NPI:1811943467
Name:ADVANCED PEDIATRIC CARE, INC.
Entity type:Organization
Organization Name:ADVANCED PEDIATRIC CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:SHAFFER
Authorized Official - Last Name:BASS
Authorized Official - Suffix:X
Authorized Official - Credentials:MS
Authorized Official - Phone:409-832-3304
Mailing Address - Street 1:PO BOX 7590
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77726-7590
Mailing Address - Country:US
Mailing Address - Phone:409-832-3304
Mailing Address - Fax:409-835-2799
Practice Address - Street 1:3330 FANNIN ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-3801
Practice Address - Country:US
Practice Address - Phone:409-832-3304
Practice Address - Fax:409-835-2799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX007953251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX162591501Medicaid
TX001004272Medicaid
TXHH307HOtherBCBS PROVIDER NUMBER
TX67-7648Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER