Basic Information
| Provider Information | |||||||||
| NPI: | 1881622199 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEDIATRIC HOME NURSING SERVICES | ||||||||
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| OtherOrganizationName: | AVEANNA HEALTHCARE | ||||||||
| 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: | 1770248874 | ||||||||
| FaxNumber: | 7702488192 | ||||||||
| Practice Location | |||||||||
| Address1: | 2250 WEHRLE DR | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142217037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7162762123 | ||||||||
| FaxNumber: | 7162762129 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 01/02/2019 | ||||||||
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| AuthorizedOfficialLastName: | WHITESIDE | ||||||||
| AuthorizedOfficialFirstName: | VICKI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| 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 | 251J00000X | 0577L003 | NY | Y | Agencies | Nursing Care |
ID Information
| ID | Type | State | Issuer | Description | 01853763 | 05 | NY | MEDICAID | 01855930 | 05 | NY | MEDICAID |