Basic Information
Provider Information | |||||||||
NPI: | 1063452605 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MEDCARE PEDIATRIC NURSING, LP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 12371 S KIRKWOOD RD | ||||||||
Address2: |   | ||||||||
City: | STAFFORD | ||||||||
State: | TX | ||||||||
PostalCode: | 774772836 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7139959292 | ||||||||
FaxNumber: | 7139954402 | ||||||||
Practice Location | |||||||||
Address1: | 12371 S KIRKWOOD RD | ||||||||
Address2: |   | ||||||||
City: | STAFFORD | ||||||||
State: | TX | ||||||||
PostalCode: | 774772836 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7139959292 | ||||||||
FaxNumber: | 7139954402 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2006 | ||||||||
LastUpdateDate: | 05/29/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KINKADE | ||||||||
AuthorizedOfficialFirstName: | PAIGE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO - ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 7139959292 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MEDCARE PEDIATRIC GROUP, LP | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251J00000X | 010415 | TX | N |   | Agencies | Nursing Care |   | 251F00000X | 010415 | TX | N |   | Agencies | Home Infusion |   | 251E00000X | 010415 | TX | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | 181090501 | 05 | TX |   | MEDICAID | 010415 | 01 | TX | HOME & COMMUNITY SUPPORT SERVICES - LHH CATEGORY | OTHER |