Provider Demographics
NPI:1063800712
Name:ANGEL HEARTS PEDIATRIC CARE, LLC
Entity type:Organization
Organization Name:ANGEL HEARTS PEDIATRIC CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFIICIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:J
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:570-875-9094
Mailing Address - Street 1:44 E INDEPENDENCE ST
Mailing Address - Street 2:
Mailing Address - City:SHAMOKIN
Mailing Address - State:PA
Mailing Address - Zip Code:17872-6804
Mailing Address - Country:US
Mailing Address - Phone:570-648-6100
Mailing Address - Fax:570-648-6104
Practice Address - Street 1:44 E INDEPENDENCE ST
Practice Address - Street 2:
Practice Address - City:SHAMOKIN
Practice Address - State:PA
Practice Address - Zip Code:17872-6804
Practice Address - Country:US
Practice Address - Phone:570-648-6100
Practice Address - Fax:570-648-6104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-05
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA05640501314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1029803430001Medicaid