Healthcare Provider Details

I. General information

NPI: 1790041010
Provider Name (Legal Business Name): PAVILION HEALTHCARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2012
Last Update Date: 04/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5916 W PICO BLVD
LOS ANGELES CA
90035-2615
US

IV. Provider business mailing address

5120 W GOLDLEAF CIR STE 400
LOS ANGELES CA
90056-1297
US

V. Phone/Fax

Practice location:
  • Phone: 323-939-3184
  • Fax: 323-939-1966
Mailing address:
  • Phone: 323-596-2145
  • Fax: 323-596-4645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number910000145
License Number StateCA

VIII. Authorized Official

Name: MR. STEPHEN REISSMAN
Title or Position: CEO/CHAIRMAN
Credential:
Phone: 310-574-3733