Basic Information
| Provider Information | |||||||||
| NPI: | 1104266238 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PAVILION OPERATIONS, LLC | ||||||||
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| OtherOrganizationName: | CORNING CENTER FOR REHABILITATION AND HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4770 WHITE PLAINS RD | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104701104 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 205 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | CORNING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148302809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189319700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2013 | ||||||||
| LastUpdateDate: | 03/31/2019 | ||||||||
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| AuthorizedOfficialLastName: | ROZENBERG | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 7189319700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 00352185 | 05 | NY | MEDICAID |