Healthcare Provider Details

I. General information

NPI: 1609111558
Provider Name (Legal Business Name): MASTER PEDIATRIC HOME CARE,P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2012
Last Update Date: 10/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10333 HARWIN DR
HOUSTON TX
77036-1545
US

IV. Provider business mailing address

10333 HARWIN DR STE 200
HOUSTON TX
77036-1545
US

V. Phone/Fax

Practice location:
  • Phone: 713-640-5809
  • Fax:
Mailing address:
  • Phone: 713-640-5809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number015378
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number015378
License Number StateTX

VIII. Authorized Official

Name: MR. CLAUDE NATHANIEL JACKSON IV
Title or Position: ADMINISTRATOR
Credential: M.ED., CCC-SLP
Phone: 832-656-7775