Provider Demographics
NPI:1619495918
Name:MOUNT ROYAL VILLA LLC
Entity Type:Organization
Organization Name:MOUNT ROYAL VILLA LLC
Other - Org Name:THE PAVILION REHABILITATION AND NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EPHRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:LAHASKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-772-3668
Mailing Address - Street 1:270 MADISON AVE FL 17
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-0601
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13900 BENNETT RD
Practice Address - Street 2:
Practice Address - City:NORTH ROYALTON
Practice Address - State:OH
Practice Address - Zip Code:44133
Practice Address - Country:US
Practice Address - Phone:440-237-7966
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-07
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0243851Medicaid
OH1138NOtherOHIO DEPARTMENT OF HEALTH HOME NUMBER