Healthcare Provider Details

I. General information

NPI: 1720499932
Provider Name (Legal Business Name): PEDIATRIC SERVICES OF AMERICA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2014
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 MAIN ST UNIT 350
NORWICH CT
06360-5760
US

IV. Provider business mailing address

400 INTERSTATE NORTH PKWY SE STE 1600
ATLANTA GA
30339-5047
US

V. Phone/Fax

Practice location:
  • Phone: 860-383-1909
  • Fax: 860-383-1914
Mailing address:
  • Phone: 470-464-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number9612701-PSO OFFICE
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State

VIII. Authorized Official

Name: SHANNON DRAKE
Title or Position: CHIEF LEGAL OFFICER
Credential:
Phone: 470-464-8000