Basic Information
| Provider Information | |||||||||
| NPI: | 1184819740 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY PROGRESS COMMITTEE INC. THE PAVILION CPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1194 | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370881194 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 152 S COLLEGE ST | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370873643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288755447 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2007 | ||||||||
| LastUpdateDate: | 05/12/2009 | ||||||||
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| AuthorizedOfficialLastName: | ARNOLD | ||||||||
| AuthorizedOfficialFirstName: | GREG | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2288755447 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 300 | TN | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 7440606 | 05 | TN | MEDICAID |