Healthcare Provider Details

I. General information

NPI: 1942723085
Provider Name (Legal Business Name): PAVILION AT KENTON FOR NURSING AND REHABILITATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2017
Last Update Date: 03/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E 20TH ST
COVINGTON KY
41014-1583
US

IV. Provider business mailing address

156 BEACH 9TH ST APT 9F
FAR ROCKAWAY NY
11691-5636
US

V. Phone/Fax

Practice location:
  • Phone: 859-283-6600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: RAFAEL A MOERMAN
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 848-299-3662