Provider Demographics
NPI:1780934976
Name:PAVILLON GREENVILLE OUTPATIENT SERVICES
Entity type:Organization
Organization Name:PAVILLON GREENVILLE OUTPATIENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:NATALIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FRYAR
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, CACII
Authorized Official - Phone:864-241-6688
Mailing Address - Street 1:101 PELHAM COMMONS BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4974
Mailing Address - Country:US
Mailing Address - Phone:864-241-6688
Mailing Address - Fax:864-241-6682
Practice Address - Street 1:101 PELHAM COMMONS BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4974
Practice Address - Country:US
Practice Address - Phone:864-241-6688
Practice Address - Fax:864-241-6682
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PAVILLON INTERNATIONAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-09-14
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCOTP 0102261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1023345139OtherNPI