Provider Demographics
NPI:1043209570
Name:PARKWAY PAVILION HEALTHCARE
Entity Type:Organization
Organization Name:PARKWAY PAVILION HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOM
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENYSE
Authorized Official - Middle Name:L N
Authorized Official - Last Name:HICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-745-8698
Mailing Address - Street 1:1157 ENFIELD ST
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-4329
Mailing Address - Country:US
Mailing Address - Phone:860-745-8698
Mailing Address - Fax:860-253-9184
Practice Address - Street 1:1157 ENFIELD ST
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-4329
Practice Address - Country:US
Practice Address - Phone:860-745-8698
Practice Address - Fax:860-253-9184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2213-C314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT075195BMedicare ID - Type Unspecified