Provider Demographics
NPI:1235432030
Name:PAVILION OF REDEMPTION HEALTHCARE SYSTEMS, INC.
Entity Type:Organization
Organization Name:PAVILION OF REDEMPTION HEALTHCARE SYSTEMS, INC.
Other - Org Name:P.O.R. HOME HELATHCARE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR & CEO
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:O
Authorized Official - Last Name:AWOFODU
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:281-983-3500
Mailing Address - Street 1:10925 BEECHNUT ST
Mailing Address - Street 2:B204-60
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77072-4351
Mailing Address - Country:US
Mailing Address - Phone:281-983-3500
Mailing Address - Fax:281-983-3502
Practice Address - Street 1:10925 BEECHNUT ST
Practice Address - Street 2:B204-60
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77072-4351
Practice Address - Country:US
Practice Address - Phone:281-983-3500
Practice Address - Fax:281-983-3502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-16
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX014000251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE AT THIS TIME