Provider Demographics
NPI:1376620120
Name:PAVILION MEDICAL HOME CARE & STAFFING, LLC
Entity Type:Organization
Organization Name:PAVILION MEDICAL HOME CARE & STAFFING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GIBSON
Authorized Official - Middle Name:IYEKE
Authorized Official - Last Name:ERHUNMWUNSE
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:703-299-9898
Mailing Address - Street 1:4115 ANNANDALE RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-2500
Mailing Address - Country:US
Mailing Address - Phone:703-299-9898
Mailing Address - Fax:703-299-9595
Practice Address - Street 1:4115 ANNANDALE RD
Practice Address - Street 2:SUITE 202
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-2500
Practice Address - Country:US
Practice Address - Phone:703-299-9898
Practice Address - Fax:703-299-9595
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PAVILION MEDICAL HOME CARE & STAFFING, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-01
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAHCO-O7389251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
497636Medicare Oscar/Certification