Healthcare Provider Details

I. General information

NPI: 1073588141
Provider Name (Legal Business Name): PAVILION CARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 07/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 FULTON ST
SIDNEY OH
45365-3203
US

IV. Provider business mailing address

705 FULTON ST
SIDNEY OH
45365-3203
US

V. Phone/Fax

Practice location:
  • Phone: 937-492-9591
  • Fax: 937-498-0529
Mailing address:
  • Phone: 937-492-9591
  • Fax: 937-498-0529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2308078
License Number StateOH

VIII. Authorized Official

Name: MS. CAROL J GROEBER
Title or Position: VICE PRESIDENT/MIS
Credential:
Phone: 937-964-8974