Provider Demographics
NPI:1205813490
Name:OTTAWA PAVILION, LTD.
Entity Type:Organization
Organization Name:OTTAWA PAVILION, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY-TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-679-8219
Mailing Address - Street 1:704 E GLOVER ST
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350-4131
Mailing Address - Country:US
Mailing Address - Phone:815-431-4900
Mailing Address - Fax:815-434-2376
Practice Address - Street 1:704 E GLOVER ST
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350-4131
Practice Address - Country:US
Practice Address - Phone:815-431-4900
Practice Address - Fax:815-434-2376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0039230314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
IL=========001Medicaid