Healthcare Provider Details

I. General information

NPI: 1689224248
Provider Name (Legal Business Name): PAVILION OUTPATIENT THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2019
Last Update Date: 09/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4115 ANNANDALE RD STE 202
ANNANDALE VA
22003-2500
US

IV. Provider business mailing address

4115 ANNANDALE RD STE 202
ANNANDALE VA
22003-2500
US

V. Phone/Fax

Practice location:
  • Phone: 703-299-9898
  • Fax: 703-299-9595
Mailing address:
  • Phone: 703-299-9898
  • Fax: 703-299-9595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: GIBSON ERHUNMWUNSE
Title or Position: CEO
Credential: CRNP
Phone: 703-299-9898