Provider Demographics
NPI:1013163377
Name:EPIC PEDIATRIC THERAPY, LP.
Entity Type:Organization
Organization Name:EPIC PEDIATRIC THERAPY, LP.
Other - Org Name:AVEANNA HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR REGULATORY LICENSING
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITESIDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-248-8740
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:770-248-8740
Mailing Address - Fax:
Practice Address - Street 1:9616 N LAMAR BLVD
Practice Address - Street 2:SUITE 105
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78753-4152
Practice Address - Country:US
Practice Address - Phone:512-527-9608
Practice Address - Fax:512-527-9618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67-6535261QR0400X
TX648140002261QR0400X
TX648140024261QR0400X
261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX676535Medicare Oscar/Certification