NPIMap

Organization Active NPI

Pavilion Medical Home Care & Staffing, LLC

  • Home Health Agency
  • Annandale, VA
National Provider Identifier
1376620120
Registry record updated Feb 22, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Home Health AgencyTaxonomy code 251E00000X
License
HCO-O7389 Issued in VA
Legal business name
PAVILION MEDICAL HOME CARE & STAFFING, LLC
Practice address
4115 Annandale Rd
Suite 202
Annandale, VA 22003-2500
Phone
(703) 299-9898
Fax
(703) 299-9595
NPI assigned
Nov 1, 2006
Organization subpart
Yes
Parent organization
PAVILION MEDICAL HOME CARE & STAFFING, LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Feb 22, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Gibson Iyeke Erhunmwunse, CRNPNPI 1710080205
Title
Ceo
Phone
(703) 299-9898

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Home Health Agency 251E00000X HCO-O7389 VA Primary

Addresses

Primary practice location

4115 Annandale Rd
Suite 202
Annandale, VA 22003-2500

Mailing address

4115 Annandale Rd
Suite 202
Annandale, VA 22003-2500
Phone (703) 299-9898

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in VA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20070223000217 VA Part A Provider - Home Health Agency 2567564453 Practice locations: Annandale, VA; Manassas, VA

Home health agency certification: CCN 497636

Legal name
PAVILION MEDICAL HOME CARE & STAFFING LLC
Certification status
Active
Provider type (POS)
Home health agency
Participating since
Apr 1, 2008
Last certification
Aug 21, 2019
Ownership / control type
Proprietary
Organization structure
LLCProprietary
Incorporated
May 31, 2006 in VA
Enrollment address
4115 Annandale Rd 202
Annandale, VA 22003-2500

Care Compare: Home health agency

Medicare Care Compare
Listed as
Pavilion Medical Home Care & Staffing, LLCCCN 497636
Overall star rating
4 of 5
Ownership
Proprietary
Certified
Apr 1, 2008
Medicare certification status
ActiveFrom the Provider of Services file
Services
Nursing, Medical social, Home health aide, Physical therapy, Speech pathology, Occupational therapy

National Provider Directory

National Provider Directory
Part of
Pavilion Medical Home Care Staffing LLC

Member organizations 1

Organizations listed as members of this organization in the National Provider Directory.

Locations

9300 Forest Point Cir
#164
Manassas, VA 20110
Phone (703) 530-9898

Ownership & related parties

All disclosed owners & managing parties 3

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Gibson Erhunmwunse Individual 5% Or Greater Direct Ownership InterestCeo Jul 8, 2006 50%
Corporate OfficerCeo Jul 8, 2006
Mary Kamara Erhunmwunse Individual 5% Or Greater Direct Ownership InterestOwner Jul 8, 2006 50%
Kimberly L Rojas Individual W-2 Managing EmployeeDirector of Operations May 2, 2012

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

Affiliated clinicians 15

Clinicians who list this facility as an affiliation in Medicare Care Compare.

View all 15

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1162339200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1329868800000",
    "number": "1376620120",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4115 ANNANDALE RD",
            "address_2": "SUITE 202",
            "city": "ANNANDALE",
            "state": "VA",
            "postal_code": "220032500",
            "telephone_number": "703-299-9898",
            "fax_number": "703-299-9595"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4115 ANNANDALE RD",
            "address_2": "SUITE 202",
            "city": "ANNANDALE",
            "state": "VA",
            "postal_code": "220032500",
            "telephone_number": "703-299-9898",
            "fax_number": "703-299-9595"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PAVILION MEDICAL HOME CARE & STAFFING, LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PAVILION MEDICAL HOME CARE & STAFFING, LLC",
        "enumeration_date": "2006-11-01",
        "last_updated": "2012-02-22",
        "status": "A",
        "authorized_official_last_name": "ERHUNMWUNSE",
        "authorized_official_first_name": "GIBSON",
        "authorized_official_middle_name": "IYEKE",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "703-299-9898",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "CRNP"
    },
    "taxonomies": [
        {
            "code": "251E00000X",
            "taxonomy_group": "",
            "desc": "Home Health",
            "state": "VA",
            "license": "HCO-O7389",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Annandale, VA

Sources for this page

Verify at the official NPI Registry.