Basic Information
| Provider Information | |||||||||
| NPI: | 1417451949 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AJ SUBURBAN PAVILION OPCO LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SUBURBAN PAVILION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 555 ANTHONY WAYNE TRL | ||||||||
| Address2: | |||||||||
| City: | WATERVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 435661516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164758880 | ||||||||
| FaxNumber: | 2165874806 | ||||||||
| Practice Location | |||||||||
| Address1: | 20265 EMERY RD | ||||||||
| Address2: | |||||||||
| City: | NORTH RANDALL | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441284122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164758880 | ||||||||
| FaxNumber: | 2165874806 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2018 | ||||||||
| LastUpdateDate: | 04/26/2018 | ||||||||
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| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | HAYLEY | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | ATTORNEY | ||||||||
| AuthorizedOfficialTelephone: | 2167063936 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1373N | OH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1373N | 01 | OH | OHIO DEPARTMENT OF HEALTH | OTHER |