Basic Information
| Provider Information | |||||||||
| NPI: | 1376218487 | ||||||||
| 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: | 4704648000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2005 VISTA PKWY STE 100A | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334116700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616835758 | ||||||||
| FaxNumber: | 5616833416 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2021 | ||||||||
| LastUpdateDate: | 03/11/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STRANGE | ||||||||
| AuthorizedOfficialFirstName: | HARMON | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4704648000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QR0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
No ID Information.