Provider Demographics
NPI:1073008504
Name:PAVILION INFUSION THERAPY INC
Entity Type:Organization
Organization Name:PAVILION INFUSION THERAPY INC
Other - Org Name:LIFE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:DURKIN
Authorized Official - Suffix:
Authorized Official - Credentials:FHFMA
Authorized Official - Phone:904-202-5887
Mailing Address - Street 1:1660 PRUDENTIAL DRIVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207
Mailing Address - Country:US
Mailing Address - Phone:904-202-5887
Mailing Address - Fax:
Practice Address - Street 1:1301 PALM AVENUE
Practice Address - Street 2:SUITE 220
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207
Practice Address - Country:US
Practice Address - Phone:904-202-5887
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PAVILION INFUSION THERAPY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-06-27
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies