Basic Information
| Provider Information | |||||||||
| NPI: | 1447584032 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PYRA MED HEALTH SERVICES, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | AVEANNA HEATLHCARE | ||||||||
| 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: | 1505 CALLE DEL NORTE | ||||||||
| Address2: | SUITE 440 | ||||||||
| City: | LAREDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9567226221 | ||||||||
| FaxNumber: | 9567226275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2009 | ||||||||
| LastUpdateDate: | 04/29/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHITESIDE | ||||||||
| AuthorizedOfficialFirstName: | VICKI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AVP REGULATORY LICENSING | ||||||||
| AuthorizedOfficialTelephone: | 4704648000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | N | Agencies | Home Health | 251J00000X | N | Agencies | Nursing Care | 251E00000X | 14043-LICENSED HCSSA | TX | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 209364301 | 05 | TX | MEDICAID |