Provider Demographics
NPI:1689224248
Name:PAVILION OUTPATIENT THERAPY LLC
Entity Type:Organization
Organization Name:PAVILION OUTPATIENT THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GIBSON
Authorized Official - Middle Name:
Authorized Official - Last Name:ERHUNMWUNSE
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:703-299-9898
Mailing Address - Street 1:4115 ANNANDALE RD STE 202
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-2500
Mailing Address - Country:US
Mailing Address - Phone:703-299-9898
Mailing Address - Fax:703-299-9595
Practice Address - Street 1:4115 ANNANDALE RD STE 202
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-2500
Practice Address - Country:US
Practice Address - Phone:703-299-9898
Practice Address - Fax:703-299-9595
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PAVILION MEDICAL HOME CARE & STAFFING, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty