Basic Information
| Provider Information | |||||||||
| NPI: | 1275069874 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEDIATRIC SERVICES OF AMERICA, LLC | ||||||||
| 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: | 7704411580 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 803 JENKS AVE STE 6 | ||||||||
| Address2: | |||||||||
| City: | PANAMA CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324012568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8503877685 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2017 | ||||||||
| LastUpdateDate: | 03/29/2022 | ||||||||
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| AuthorizedOfficialLastName: | AFSHAR | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4704648000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251J00000X | N | Agencies | Nursing Care | 251E00000X | Y | Agencies | Home Health |
No ID Information.