Provider Demographics
NPI:1861935033
Name:PEDIATRIC PT LLC.
Entity type:Organization
Organization Name:PEDIATRIC PT LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TANJA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-235-2524
Mailing Address - Street 1:1106 HERITAGE LN NE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36265-1255
Mailing Address - Country:US
Mailing Address - Phone:256-235-2524
Mailing Address - Fax:256-236-2573
Practice Address - Street 1:1705 LEIGHTON AVE
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36207-3832
Practice Address - Country:US
Practice Address - Phone:256-235-2524
Practice Address - Fax:256-236-2573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-21
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL890001880Medicaid