MEDICARE: PEDIALIFE HOME HEALTH INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1811264708
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIALIFE HOME HEALTH INC.

Provider Business Mailing Address
First Line	:	5500 E LOOP 820 S
Second Line	:	SUITE 207
City	:	FORT WORTH
State	:	TX
Zip	:	76119-6569
Country	:	US
Telephone Number	:	817-563-5433
Fax Number	:	817-563-5435

Provider Business Practice Location Address
First Line	:	5500 E LOOP 820 S
Second Line	:	SUITE 207
City	:	FORT WORTH
State	:	TX
Zip	:	76119-6569
Country	:	US
Telephone Number	:	817-563-5433
Fax Number	:	817-563-5435

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. DEVELLE MARIE DEDRICK
Credential	:	MSN, RN
Telephone Number	:	817-296-5938

Provider Enumeration Date	:	11/21/2011
Last Update Date	:	06/25/2012

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