Provider Demographics
NPI:1164446530
Name:PEDIATRIC SERVICES OF AMERICA, INC.
Entity Type:Organization
Organization Name:PEDIATRIC SERVICES OF AMERICA, INC.
Other - Org Name:PSA HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:VALENTINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-248-8757
Mailing Address - Street 1:310 TECHNOLOGY PKWY
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-2932
Mailing Address - Country:US
Mailing Address - Phone:770-441-1580
Mailing Address - Fax:770-248-8192
Practice Address - Street 1:4051 PHILLIPS HWY
Practice Address - Street 2:SUITE 2
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-9305
Practice Address - Country:US
Practice Address - Phone:904-731-0030
Practice Address - Fax:904-731-0766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPPC60080961261QM3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM3000XAmbulatory Health Care FacilitiesClinic/CenterMedically Fragile Infants and Children Day Care