Basic Information
| Provider Information | |||||||||
| NPI: | 1720499932 | ||||||||
| 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: | 7702488740 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 55 MAIN ST UNIT 350 | ||||||||
| Address2: | |||||||||
| City: | NORWICH | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063605760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603831909 | ||||||||
| FaxNumber: | 8603831914 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2014 | ||||||||
| LastUpdateDate: | 03/08/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WHITESIDE | ||||||||
| AuthorizedOfficialFirstName: | VICKI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AVP REGULATORY LICENSING | ||||||||
| AuthorizedOfficialTelephone: | 7704411580 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251J00000X | N | Agencies | Nursing Care | 251E00000X | 9612701-PSO OFFICE | CT | Y | Agencies | Home Health |
No ID Information.