=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295757227
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC SERVICES OF AMERICA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2006
-----------------------------------------------------
Last Update Date | 01/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2005 VISTA PKWY SUITE 110 A
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33411-2719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-683-5758
-----------------------------------------------------
Fax | 561-683-3416
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 INTERSTATE NORTH PKWY SE STE 1600
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30339-5047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 470-464-8000
-----------------------------------------------------
Fax | 770-248-8192
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MATTHEW BUCKHALTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 470-464-8000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM3000X
-----------------------------------------------------
Taxonomy Name | Medically Fragile Infants and Children Day Care
-----------------------------------------------------
License Number | PPC6010096
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------