Basic Information
| Provider Information | |||||||||
| NPI: | 1568633071 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEDIATRIA HEALTHCARE, 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: | 7702488740 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2420 DOUBLE CHURCHES RD STE B | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319092984 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063223693 | ||||||||
| FaxNumber: | 7063228443 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2008 | ||||||||
| LastUpdateDate: | 02/08/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHITESIDE | ||||||||
| AuthorizedOfficialFirstName: | VICKI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, REGULATORY LICENSING | ||||||||
| AuthorizedOfficialTelephone: | 7702488740 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PEDIATRIA HEALTHCARE, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251J00000X | 106-R-0416 | GA | Y | Agencies | Nursing Care |
ID Information
| ID | Type | State | Issuer | Description | 804642159A | 05 | GA | MEDICAID |