MEDICARE: PAVILION GUEST HOME

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	311ZA0620X	Adult Care Home Facility	ALH 4489	AZ

General Provider Information

NPI Number	:	1194861716
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAVILION GUEST HOME

Provider Business Mailing Address
First Line	:	2955 E. MALLORY ST.
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85213
Country	:	US
Telephone Number	:	480-654-8329
Fax Number	:	480-830-4113

Provider Business Practice Location Address
First Line	:	2955 E MALLORY ST
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85213-1667
Country	:	US
Telephone Number	:	480-654-8329
Fax Number	:	480-830-4113

Authorized Official
Title or Position	:	OWNER
Name	:	MARIETA G. HUGO
Credential	:
Telephone Number	:	480-654-8329

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	08/22/2020

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Directions to “PAVILION GUEST HOME ” Practice Location

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