Provider Demographics
NPI:1518478585
Name:RAYMOND, EDENA PAVILIS (SOLO PROVIDER)
Entity Type:Individual
Prefix:
First Name:EDENA
Middle Name:PAVILIS
Last Name:RAYMOND
Suffix:
Gender:F
Credentials:SOLO PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9822 BROOKFIELD FARM CT APT 203
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-7575
Mailing Address - Country:US
Mailing Address - Phone:813-458-2859
Mailing Address - Fax:813-398-5801
Practice Address - Street 1:9822 BROOKFIELD FARM CT APT 203
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-7575
Practice Address - Country:US
Practice Address - Phone:813-458-2859
Practice Address - Fax:813-398-5801
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-18
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017204400Medicaid