Provider Demographics
NPI:1134178098
Name:PEDIATRIC HOME CARE, INC.
Entity type:Organization
Organization Name:PEDIATRIC HOME CARE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCKHALTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-464-8000
Mailing Address - Street 1:400 INTERSTATE NORTH PKWY SE STE 1600
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-5047
Mailing Address - Country:US
Mailing Address - Phone:470-464-8000
Mailing Address - Fax:770-248-8192
Practice Address - Street 1:1120 NORTH MULLAN ROAD
Practice Address - Street 2:SUITE 206
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-4074
Practice Address - Country:US
Practice Address - Phone:509-368-9252
Practice Address - Fax:509-368-9594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00000344251E00000X, 251E00000X
WAPF00057031332B00000X, 3336H0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806198700Medicaid
WA7331622Medicaid
WA6025159Medicaid
ID806189200Medicaid
MT0213350Medicaid
MT0561646Medicaid
WA9051780Medicaid
WA6025159Medicaid
MT0213350Medicaid