Provider Demographics
NPI:1417451949
Name:AJ SUBURBAN PAVILION OPCO LLC
Entity Type:Organization
Organization Name:AJ SUBURBAN PAVILION OPCO LLC
Other - Org Name:SUBURBAN PAVILION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ATTORNEY
Authorized Official - Prefix:
Authorized Official - First Name:HAYLEY
Authorized Official - Middle Name:B
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-706-3936
Mailing Address - Street 1:555 ANTHONY WAYNE TRL
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43566-1516
Mailing Address - Country:US
Mailing Address - Phone:216-475-8880
Mailing Address - Fax:216-587-4806
Practice Address - Street 1:20265 EMERY RD
Practice Address - Street 2:
Practice Address - City:NORTH RANDALL
Practice Address - State:OH
Practice Address - Zip Code:44128-4122
Practice Address - Country:US
Practice Address - Phone:216-475-8880
Practice Address - Fax:216-587-4806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-20
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1373N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1373NOtherOHIO DEPARTMENT OF HEALTH