Healthcare Provider Details

I. General information

NPI: 1063887438
Provider Name (Legal Business Name): PAVILION PEDIATRIC CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2015
Last Update Date: 03/06/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3711 N. EVERBROOK LANE
MUNCIE IN
47304-5270
US

IV. Provider business mailing address

3711 N. EVERBROOK LANE
MUNCIE IN
47304-5270
US

V. Phone/Fax

Practice location:
  • Phone: 765-231-9494
  • Fax: 765-587-4456
Mailing address:
  • Phone: 765-231-9494
  • Fax: 765-587-4456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. NICOLE RECTOR
Title or Position: OWNER
Credential: NP/OWNER
Phone: 765-231-9494