Provider Demographics
NPI:1457601148
Name:MJ CHILDREN PAVILLION, INC
Entity Type:Organization
Organization Name:MJ CHILDREN PAVILLION, INC
Other - Org Name:MJPAVILLION, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TYRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-462-5613
Mailing Address - Street 1:728 S ENDEAVOUR DR
Mailing Address - Street 2:
Mailing Address - City:WINTER SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32708-5167
Mailing Address - Country:US
Mailing Address - Phone:407-462-5613
Mailing Address - Fax:407-699-4255
Practice Address - Street 1:728 S ENDEAVOUR DR
Practice Address - Street 2:
Practice Address - City:WINTER SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32708-5167
Practice Address - Country:US
Practice Address - Phone:407-462-5613
Practice Address - Fax:407-699-4255
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MJ CHILDREN PAVILLION, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-09-11
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18307100308253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL230569100Medicaid