Basic Information
| Provider Information | |||||||||
| NPI: | 1891745808 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC SPECIAL CARE, INC. | ||||||||
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| OtherOrganizationName: | AVEANNA | ||||||||
| 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 | ||||||||
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| Practice Location | |||||||||
| Address1: | 39205 COUNTRY CLUB DR STE C26 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483315718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485574800 | ||||||||
| FaxNumber: | 2485573998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 12/04/2019 | ||||||||
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| AuthorizedOfficialLastName: | WHITESIDE | ||||||||
| AuthorizedOfficialFirstName: | VICKI | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR REGULATORY LICENSING | ||||||||
| AuthorizedOfficialTelephone: | 7702488740 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | N | Agencies | Home Health | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | 5301008368 | MI | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 3336H0001X | N | Suppliers | Pharmacy | Home Infusion Therapy Pharmacy | 251J00000X | Y | Agencies | Nursing Care |
ID Information
| ID | Type | State | Issuer | Description | 2368214 | 01 | OTHER ID NUMBER | OTHER | 2934849 | 05 | MI | MEDICAID | 4360676 | 05 | MI | MEDICAID |