Healthcare Provider Details

I. General information

NPI: 1598260952
Provider Name (Legal Business Name): PAVILION AT PIKETON FOR NURSING AND REHABILITATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 07/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7143 US HIGHWAY 23
PIKETON OH
45661-9527
US

IV. Provider business mailing address

1 VALLEY GREENS DR
VALLEY STREAM NY
11581-3634
US

V. Phone/Fax

Practice location:
  • Phone: 740-289-2394
  • Fax: 740-289-2231
Mailing address:
  • Phone: 848-299-3662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number1621N
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: RAFAEL A MOERMAN
Title or Position: MANAGING MEMBER
Credential:
Phone: 848-299-3662