Provider Demographics
NPI:1104214741
Name:PAVILIONIS, PHIL (MS, LAT, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:PHIL
Middle Name:
Last Name:PAVILIONIS
Suffix:
Gender:M
Credentials:MS, LAT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:395 BOOTH ST
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-1318
Mailing Address - Country:US
Mailing Address - Phone:775-333-5050
Mailing Address - Fax:
Practice Address - Street 1:395 BOOTH ST
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-1318
Practice Address - Country:US
Practice Address - Phone:775-232-4694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-06
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV05060452255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer