Provider Demographics
NPI:1316336266
Name:MJ CHILDRENS PAVILLION, INS
Entity type:Organization
Organization Name:MJ CHILDRENS PAVILLION, INS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TYRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-699-4255
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:
Mailing Address - Fax:
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:407-699-4255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MJ CHILDRENS PAVILLION, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-01-15
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12589310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1457601148Medicaid