Healthcare Provider Details

I. General information

NPI: 1194861716
Provider Name (Legal Business Name): PAVILION GUEST HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2955 E MALLORY ST
MESA AZ
85213-1667
US

IV. Provider business mailing address

2955 E. MALLORY ST.
MESA AZ
85213
US

V. Phone/Fax

Practice location:
  • Phone: 480-654-8329
  • Fax: 480-830-4113
Mailing address:
  • Phone: 480-654-8329
  • Fax: 480-830-4113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberALH 4489
License Number StateAZ

VIII. Authorized Official

Name: MARIETA G. HUGO
Title or Position: OWNER
Credential:
Phone: 480-654-8329