Basic Information
| Provider Information | |||||||||
| NPI: | 1205813490 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OTTAWA PAVILION, LTD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 704 E GLOVER ST | ||||||||
| Address2: | |||||||||
| City: | OTTAWA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 613504131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154314900 | ||||||||
| FaxNumber: | 8154342376 | ||||||||
| Practice Location | |||||||||
| Address1: | 704 E GLOVER ST | ||||||||
| Address2: | |||||||||
| City: | OTTAWA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 613504131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8154314900 | ||||||||
| FaxNumber: | 8154342376 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2005 | ||||||||
| LastUpdateDate: | 01/14/2015 | ||||||||
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| AuthorizedOfficialLastName: | MAUER | ||||||||
| AuthorizedOfficialFirstName: | MARSHALL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY-TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 8476798219 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0039230 | IL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.