Provider Demographics
NPI:1194861716
Name:PAVILION GUEST HOME
Entity Type:Organization
Organization Name:PAVILION GUEST HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIETA
Authorized Official - Middle Name:G
Authorized Official - Last Name:HUGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-654-8329
Mailing Address - Street 1:2955 E. MALLORY ST.
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213
Mailing Address - Country:US
Mailing Address - Phone:480-654-8329
Mailing Address - Fax:480-830-4113
Practice Address - Street 1:2955 E MALLORY ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-1667
Practice Address - Country:US
Practice Address - Phone:480-654-8329
Practice Address - Fax:480-830-4113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALH 4489311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home