=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023345139
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAVILLON GREENVILLE OUTPATIENT SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2009
-----------------------------------------------------
Last Update Date | 07/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 PELHAM COMMONS BLVD
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29615-4974
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-241-6688
-----------------------------------------------------
Fax | 866-990-3066
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 PELHAM COMMONS BLVD
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29615-4974
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-241-6688
-----------------------------------------------------
Fax | 866-990-3066
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING
-----------------------------------------------------
Name | CINDY KEATOR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 828-694-2337
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number | OTP-0102
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------