Healthcare Provider Details

I. General information

NPI: 1922409069
Provider Name (Legal Business Name): PEDIATRIA HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2014
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 BERT KOUNS INDUSTRIAL LOOP SUITE 600
SHREVEPORT LA
71106-8158
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 318-415-7625
  • Fax: 318-415-7630
Mailing address:
  • Phone: 470-464-8000
  • Fax: 770-248-8192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM3000X
TaxonomyMedically Fragile Infants and Children Day Care
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW BUCKHALTER
Title or Position: CFO
Credential:
Phone: 470-464-8000