Healthcare Provider Details

I. General information

NPI: 1407096043
Provider Name (Legal Business Name): THE PAVILION FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2009
Last Update Date: 08/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 W CHURCH ST
CHAMPAIGN IL
61820-3320
US

IV. Provider business mailing address

809 W CHURCH ST
CHAMPAIGN IL
61820-3320
US

V. Phone/Fax

Practice location:
  • Phone: 217-373-1700
  • Fax:
Mailing address:
  • Phone: 217-373-1700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number0004689
License Number StateIL

VIII. Authorized Official

Name: STEVE FILTON
Title or Position: CFO/SR VP
Credential:
Phone: 610-768-3300