Healthcare Provider Details

I. General information

NPI: 1245580182
Provider Name (Legal Business Name): PAVILION HEALTHCARE SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 09/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17420 AVALON BLVD STE 206
CARSON CA
90746-1564
US

IV. Provider business mailing address

17420 AVALON BLVD STE 206
CARSON CA
90746
US

V. Phone/Fax

Practice location:
  • Phone: 310-753-1201
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateCA

VIII. Authorized Official

Name: GABRIEL C EJIZU
Title or Position: PRESIDENT
Credential:
Phone: 310-753-1201