Healthcare Provider Details

I. General information

NPI: 1043849896
Provider Name (Legal Business Name): PAVANA TREATMENT GROUP, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2020
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1560 UNION RD
GASTONIA NC
28054-2209
US

IV. Provider business mailing address

1560 UNION RD
GASTONIA NC
28054-2209
US

V. Phone/Fax

Practice location:
  • Phone: 704-490-4993
  • Fax:
Mailing address:
  • Phone: 704-490-4993
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LA0401X
TaxonomyAddiction Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MELISSA BLOCKER
Title or Position: CFO
Credential:
Phone: 864-800-3223