Healthcare Provider Details

I. General information

NPI: 1699707968
Provider Name (Legal Business Name): PEDIATRIC SERVICES OF AMERICA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9105 NE HIGHWAY 99 STE 202, BUILDING A
VANCOUVER WA
98665-8961
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 360-639-7595
  • Fax: 360-693-7262
Mailing address:
  • Phone: 470-464-8000
  • Fax: 770-248-8192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License NumberIS-423
License Number StateWA

VIII. Authorized Official

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