Provider Demographics
NPI:1447233945
Name:ESSEX PAVILION, LLC
Entity Type:Organization
Organization Name:ESSEX PAVILION, LLC
Other - Org Name:THE PAVILION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:BENOIT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-775-6663
Mailing Address - Street 1:876 FALMOUTH RD
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-2322
Mailing Address - Country:US
Mailing Address - Phone:508-775-6663
Mailing Address - Fax:508-778-9891
Practice Address - Street 1:876 FALMOUTH RD
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-2322
Practice Address - Country:US
Practice Address - Phone:508-775-6663
Practice Address - Fax:508-778-9891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0869314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0929204Medicaid
MA225503Medicare ID - Type Unspecified