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General NPI Number Information
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NPI Number | 1164310496
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Entity Type | Organization
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Legal Business Name | PAVILION PACE, LLC
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Dates
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Enumeration Date | 06/25/2025
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Last Update Date | 06/25/2025
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Provider Practice Location Address
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Address Line | 4115 ANNANDALE RD STE 100
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City | ANNANDALE
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State | VA
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Zip | 22003-2583
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Country | US
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Telephone | 240-346-7488
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Fax | 703-226-5604
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Provider Business Mailing Address
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Address Line | 4115 ANNANDALE RD STE 100
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City | ANNANDALE
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State | VA
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Zip | 22003-2583
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Country | US
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Telephone | 240-346-7488
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Fax | 703-226-5604
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Authorized Official
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Title or Position | CEO
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Name | GIBSON ERHUNMWUNSE
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Credential | DNP
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Telephone | 240-346-7488
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251T00000X
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Taxonomy Name | PACE Provider Organization
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License Number |
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License Number State |
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