Provider Demographics
NPI:1508168170
Name:PEDIATRIA HEALTHCARE, LLC
Entity Type:Organization
Organization Name:PEDIATRIA HEALTHCARE, LLC
Other - Org Name:AVEANNA HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF LEGAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:DRAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-464-8000
Mailing Address - Street 1:400 INTERSTATE NORTH PKWY SE STE 1600
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-5047
Mailing Address - Country:US
Mailing Address - Phone:470-464-8000
Mailing Address - Fax:770-248-8192
Practice Address - Street 1:1167 N WASHINGTON ST STE E
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18705-1856
Practice Address - Country:US
Practice Address - Phone:570-371-5606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-02
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA04250501251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101299280 0009Medicaid
PA04250501OtherHOME HEALTH AGENCY LICENSE
PA101299280 0009Medicaid