Provider Demographics
NPI:1073588141
Name:PAVILION CARE CENTER LLC
Entity Type:Organization
Organization Name:PAVILION CARE CENTER LLC
Other - Org Name:THE PAVILION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT/MIS
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:J
Authorized Official - Last Name:GROEBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-964-8974
Mailing Address - Street 1:705 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:OH
Mailing Address - Zip Code:45365-3203
Mailing Address - Country:US
Mailing Address - Phone:937-492-9591
Mailing Address - Fax:937-498-0529
Practice Address - Street 1:705 FULTON ST
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:OH
Practice Address - Zip Code:45365-3203
Practice Address - Country:US
Practice Address - Phone:937-492-9591
Practice Address - Fax:937-498-0529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2308078314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2308078Medicaid
OH2308078Medicaid