# ANGEL HEARTS PEDIATRIC CARE, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1063800712
- **Authorized official:** MR. RICKY J LONG CEO (AUTHORIZED OFIICIAL)
- **Authorized official phone:** (570) 875-9094

## Contact information

- **Practice address:** 44 E INDEPENDENCE ST, SHAMOKIN, PA 17872-6804
- **Practice address phone:** (570) 648-6100
- **Practice address fax:** (570) 648-6104
- **Mailing address:** 44 E INDEPENDENCE ST, SHAMOKIN, PA 17872-6804
- **Mailing address phone:** (570) 648-6100
- **Mailing address fax:** (570) 648-6104

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 314000000X | Skilled Nursing Facility | 05640501 | PA | Yes |

## Other

- **Enumeration date:** 01/05/2015
- **Last updated:** 07/01/2015

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 1029803430001 | — | PA |