MEDICARE: THE PAVILION AT JACKSONVILLE FOR NURSING AND REHABILITATION, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063097921
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE PAVILION AT JACKSONVILLE FOR NURSING AND REHABILITATION, LLC

Provider Business Mailing Address
First Line	:	1 VALLEY GREENS DR
Second Line	:
City	:	VALLEY STREAM
State	:	NY
Zip	:	11581-3634
Country	:	US
Telephone Number	:	516-865-1500
Fax Number	:

Provider Business Practice Location Address
First Line	:	1771 EDGEWOOD AVE W
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32208-3278
Country	:	US
Telephone Number	:	516-865-1500
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	RAFAEL A MOERMAN
Credential	:
Telephone Number	:	516-865-1500

Provider Enumeration Date	:	03/12/2021
Last Update Date	:	03/12/2021

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