Basic Information
Provider Information | |||||||||
NPI: | 1518132406 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PEDIATRIA HEALTHCARE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AVEANNA HEALTHCARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 400 INTERSTATE NORTH PKWY SE STE 1600 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303395047 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7702488740 | ||||||||
FaxNumber: | 7708401901 | ||||||||
Practice Location | |||||||||
Address1: | 3492 MARTIN HURST RD | ||||||||
Address2: |   | ||||||||
City: | TALLAHASSEE | ||||||||
State: | FL | ||||||||
PostalCode: | 323121702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8507013920 | ||||||||
FaxNumber: | 8507013924 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/23/2008 | ||||||||
LastUpdateDate: | 07/11/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WHITESIDE | ||||||||
AuthorizedOfficialFirstName: | VICKI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR REGULATORY LICENSING | ||||||||
AuthorizedOfficialTelephone: | 7702488740 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM3000X | 60080986 | FL | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Medically Fragile Intants and Children Day Care |
ID Information
ID | Type | State | Issuer | Description | 240024300 | 05 | FL |   | MEDICAID |