Basic Information
| Provider Information | |||||||||
| NPI: | 1982733408 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEDIATRIC SERVICES OF AMERICA, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | AVEANNA HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 CONCOURSE PKWY NE | ||||||||
| Address2: | STE 1100 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303286117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704411580 | ||||||||
| FaxNumber: | 7702488192 | ||||||||
| Practice Location | |||||||||
| Address1: | 146 NEW BRITAIN AVE | ||||||||
| Address2: | |||||||||
| City: | PLAINVILLE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607473306 | ||||||||
| FaxNumber: | 8607474064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2007 | ||||||||
| LastUpdateDate: | 03/08/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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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 | 251E00000X | Y | Agencies | Home Health |
No ID Information.