NPIMap

Pediatric Group of Acadiana LLC

Organization Active NPI Rural Health Clinic/Center · Erath, LA

NPI 1073973533 · NPPES record last updated Dec 3, 2024

Key facts

NPI
1073973533
Entity type
Organization (NPI type 2)
Primary specialty
Rural Health Clinic/Center 261QR1300X
Legal business name
PEDIATRIC GROUP OF ACADIANA LLC
Practice address
550 West Veterans Memorial Drive
Erath, LA 70533-3430
Phone
(337) 918-6341
Fax
(337) 918-6346
NPI assigned
Feb 26, 2016
Organization subpart
No

Authorized official

Name
Antoinette Rabenaldt
Title
Credentialing Coordinator
Phone
(337) 330-2576

Owners & managing parties with NPI records 10

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Owned or controlled facilities with NPI records 5

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Other NPIs with the same Medicare PAC ID 7

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Corporate family (same tax ID) 9

Organizations that report the same tax identification number in the National Provider Directory.

Facilities with the same owner 5

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners 16

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Laboratory certificates & supplier records

Name & address match These CMS records do not include an NPI. They are shown here because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
19D2104513Pediatric Group of Acadiana & Family Clinic
550 Veterans Memorial Drive, Erath, LA 70533		Certificate of waiverNov 4, 2027

Medicare participation

Medicare fee-for-service enrollment
Enrolled in LA

Rural health clinic certification: CCN 193925

Legal name
PEDIATRIC GROUP OF ACADIANA, LLC
Doing business as
PEDIATRIC GROUP OF ACADIANA & FAMILY CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jun 26, 2017
Last certification
Jun 26, 2023
Ownership / control type
1B
Organization structure
LLC · Proprietary
Incorporated
Jan 1, 2001 in LA
Enrollment address
550 West Veterans Memorial Drive
Erath, LA 70533-3430

All disclosed owners & managing parties 10

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Shawntel Marie Moore
Individual 		W-2 Managing Employee
Employed Nurse Practitioner of P		 Apr 1, 2016
Mateo Atwi
Individual 		5% Or Greater Direct Ownership Interest Dec 31, 2020 15%
Tiago Atwi
Individual 		5% Or Greater Direct Ownership Interest Dec 31, 2020 15%
Pediatric Group of Acadiana, LLC
Organization · Lafayette, LA
LLC 		5% Or Greater Direct Ownership Interest Jan 1, 2001 100%
Celina Atwi
Individual 		5% Or Greater Direct Ownership Interest Mar 9, 2016 5%
Andreas Atwi
Individual 		5% Or Greater Direct Ownership Interest Dec 31, 2020 15%
Francisco Atwi
Individual 		5% Or Greater Direct Ownership Interest Dec 31, 2020 15%
Jibran E Atwi
Individual 		5% Or Greater Direct Ownership Interest Jan 1, 2001 5%
Corporate Officer
Member and Officer of Pediatric		 Jan 1, 2001 100%
Noah E Atwi
Individual 		5% Or Greater Direct Ownership Interest Dec 31, 2020 15%
Carla Johnston
Individual 		5% Or Greater Direct Ownership Interest Dec 31, 2020 15%

All facility ownership & control disclosures 5

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
St. Martinville Maternal-Child and Adult Clinic
Saint Martinville, LA · CCN 193885		 Rural health clinic 5% Or Greater Direct Ownership Interest Jan 9, 2008
Pediatric Group of Acadiana & Church Point Clinic
Church Point, LA · CCN 193944		 Rural health clinic 5% Or Greater Direct Ownership Interest Jan 9, 2008
Waterway Pediatrics
Maurepas, LA · CCN 193949		 Rural health clinic 5% Or Greater Direct Ownership Interest Jan 9, 2008
Oxbow Family Practice
New Roads, LA · CCN 193948		 Rural health clinic 5% Or Greater Direct Ownership Interest Jan 9, 2008
Kids Clinic and Adult Wellness of Crowley
Crowley, LA · CCN 193964		 Rural health clinic 5% Or Greater Direct Ownership Interest Jan 9, 2008

Medicare enrollment records

Enrollment IDStateProvider typePAC IDDetails
O20160405001150 LA Part a Provider - Rural Health Clinic 2466476023 Practice locations: Erath, LA

National Provider Directory

Tax ID family
Pediatric Group of Acadiana (10 organizations share this tax ID)

Locations

401 Youngsville Hwy
Ste 100
Lafayette, LA 70508
Phone (337) 330-0031

2308 E Main St
Ste G
New Iberia, LA 70560
Phone (337) 367-2001

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X LA Yes

Addresses

Primary practice location

550 West Veterans Memorial Drive
Erath, LA 70533-3430

Mailing address

302 Hacker St
New Iberia, LA 70560-4508
Phone (337) 330-2576

Other names

  • Pediatric Group of Acadiana & Family Clinic Doing business as

Other providers in Erath, LA

All providers in Erath, LA · Rural Health Clinic/Center in Louisiana

Sources for this page

Verify at the official NPI Registry.