Basic Information
| Provider Information | |||||||||
| NPI: | 1013163377 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EPIC PEDIATRIC THERAPY, LP. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AVEANNA HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 INTERSTATE NORTH PKWY SE STE 1600 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303395047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702488740 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9616 N LAMAR BLVD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787534152 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5125279608 | ||||||||
| FaxNumber: | 5125279618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2008 | ||||||||
| LastUpdateDate: | 06/12/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHITESIDE | ||||||||
| AuthorizedOfficialFirstName: | VICKI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR REGULATORY LICENSING | ||||||||
| AuthorizedOfficialTelephone: | 7702488740 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | 648140024 | TX | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation | 261QR0400X | 648140002 | TX | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation | 261QR0401X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF) | 261QR0400X | 67-6535 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
No ID Information.