NPIMap

Organization Active NPI

Pediatric Group of Acadiana LLC

Doing business as Pediatric Group of Acadiana & Family Clinic

  • Rural Health Clinic/Center
  • Erath, LA
National Provider Identifier
1073973533
Registry record updated Dec 3, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
PEDIATRIC GROUP OF ACADIANA LLC
Doing business as
Pediatric Group of Acadiana & Family Clinic
Practice address
550 West Veterans Memorial Drive
Erath, LA 70533-3430
Phone
(337) 918-6341
Fax
(337) 918-6346
NPI assigned
Feb 26, 2016
Last updated
Dec 3, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 3, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

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

Specialties & licenses 1

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

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 1

  • Pediatric Group of Acadiana & Family Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in LA

Enrollment records 1

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

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1073973533. Details of each certification follow.

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
LLCProprietary
Incorporated
Jan 1, 2001 in LA
Enrollment address
550 West Veterans Memorial Drive
Erath, LA 70533-3430

Other NPIs with the same Medicare PAC ID 7

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

Laboratory certificates & supplier records

Derived by NPIMap

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

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
19D2104513Pediatric Group of Acadiana & Family Clinic550 Veterans Memorial Drive, Erath, LA 70533Certificate of waiverNov 4, 2027

National Provider Directory

National Provider Directory
Tax ID family
Pediatric GRP of Acadianall10 organizations share this tax ID, including this one

Other organizations with this tax ID 9

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

Locations

550 W Veterans Memorial Dr
Erath, LA 70533
Phone (337) 918-6341

612 Westgate Rd
Lafayette, LA 70506
Phone (337) 289-6770

Ownership & related parties

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 EmployeeEmployed 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 OfficerMember 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%

Owners & managing parties with NPI records 10

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

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 ClinicSaint Martinville, LA, CCN 193885 Rural health clinic 5% Or Greater Direct Ownership Interest Jan 9, 2008
Pediatric Group of Acadiana & Church Point ClinicChurch Point, LA, CCN 193944 Rural health clinic 5% Or Greater Direct Ownership Interest Jan 9, 2008
Waterway PediatricsMaurepas, LA, CCN 193949 Rural health clinic 5% Or Greater Direct Ownership Interest Jan 9, 2008
Oxbow Family PracticeNew Roads, LA, CCN 193948 Rural health clinic 5% Or Greater Direct Ownership Interest Jan 9, 2008
Kids Clinic and Adult Wellness of CrowleyCrowley, LA, CCN 193964 Rural health clinic 5% Or Greater Direct Ownership Interest Jan 9, 2008

Owned or controlled facilities with NPI records 5

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

Facilities with the same owner 5

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

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1456444800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1733184000000",
    "number": "1073973533",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "302 HACKER ST",
            "city": "NEW IBERIA",
            "state": "LA",
            "postal_code": "705604508",
            "telephone_number": "337-330-2576",
            "fax_number": "337-321-6295"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "550 WEST VETERANS MEMORIAL DRIVE",
            "city": "ERATH",
            "state": "LA",
            "postal_code": "705333430",
            "telephone_number": "337-918-6341",
            "fax_number": "337-918-6346"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PEDIATRIC GROUP OF ACADIANA LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-02-26",
        "last_updated": "2024-12-03",
        "certification_date": "2024-12-03",
        "status": "A",
        "authorized_official_last_name": "RABENALDT",
        "authorized_official_first_name": "ANTOINETTE",
        "authorized_official_title_or_position": "CREDENTIALING COORDINATOR",
        "authorized_official_telephone_number": "337-330-2576"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "LA",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Pediatric Group of Acadiana & Family Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Erath, LA

Sources for this page

Verify at the official NPI Registry.