The Pavilion at Crescent Lake for Nursing and Rehabilitation, LLC

Primary specialty

Skilled Nursing FacilityTaxonomy code 314000000X

Legal business name

THE PAVILION AT CRESCENT LAKE FOR NURSING AND REHABILITATION, LLC

Practice address

100 N Lake St
Crescent City, FL 32112-2620

Phone

(516) 865-1500

NPI assigned

Mar 12, 2021

Organization subpart

No

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

Authorized official

Name

Rafael A Moerman

Title

Managing Member

Phone

(516) 865-1500

Specialties & licenses 1

Addresses

Other names 1

• The Pavilion at Crescent Lake Doing business as

Medicare fee-for-service enrollment

Enrolled in FL

Enrollment records 1

Skilled nursing facility certification: CCN 105808

Legal name

THE PAVILION AT CRESCENT LAKE FOR NURSING AND REHABILITATION LLC

Doing business as

THE PAVILION AT CRESCENT LAKE

Certification status

Active

Provider type (POS)

Nursing home – SNF/NF dual certification

Participating since

Jul 1, 1993

Last certification

Aug 1, 2024

Beds

92

Ownership / control type

Limited Liability Corporation

Organization structure

LLCProprietary

Enrollment address

100 N Lake St
Crescent City, FL 32112-2620

Nursing home name

THE PAVILION AT CRESCENT LAKE

Affiliated entity

THE PAVILION GROUP

Listed as

The Pavilion at Crescent LakeCCN 105808

Overall star rating

4 of 5

Health inspections

3 of 5

Staffing

4 of 5

Quality measures

5 of 5

Type

Medicare and Medicaid

Ownership

For profit - Limited Liability company

Certified

Jul 1, 1993

Medicare certification status

ActiveFrom the Provider of Services file

Certified beds

9272.2 residents per day on average

Chain

The Pavilion Group6 facilities in the chain

Processed by Care Compare on Aug 1, 2026.

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

All disclosed owners & managing parties 16

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

Owners & managing parties with NPI records 1

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

• Moustafa M Eldick, M.D.

  • Internal Medicine Physician
  • Crescent City, FL
  • NPI 1962592907

  Adp of the SNF

  CMS ownership

Affiliated clinicians 2

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

• Moustafa M Eldick, M.D.

  • Internal Medicine Physician
  • Crescent City, FL
  • NPI 1962592907

  Nursing home

  Care Compare affiliation
• Phuc V. Tran, MD

  • Hospitalist Physician
  • Jacksonville, FL
  • NPI 1033185400

  Nursing home

  Care Compare affiliation

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

{
    "created_epoch": "1615507200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1615507200000",
    "number": "1386229250",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1 VALLEY GREENS DR",
            "city": "VALLEY STREAM",
            "state": "NY",
            "postal_code": "115813634",
            "telephone_number": "516-865-1500"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "100 N LAKE ST",
            "city": "CRESCENT CITY",
            "state": "FL",
            "postal_code": "321122620",
            "telephone_number": "516-865-1500"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "THE PAVILION AT CRESCENT LAKE FOR NURSING AND REHABILITATION, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-03-12",
        "last_updated": "2021-03-12",
        "certification_date": "2021-03-12",
        "status": "A",
        "authorized_official_last_name": "MOERMAN",
        "authorized_official_first_name": "RAFAEL",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "MANAGING MEMBER",
        "authorized_official_telephone_number": "516-865-1500"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "The Pavilion at Crescent Lake",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Sunrise Primary Care Inc
• Sunrise Primary Care Inc
• Sunrise Primary Care Inc
• T R Suggs MD Medical Clinic PA
• Mark Erik Tallaksen, D.C.
• Erica Varesi, LPN
• Vicktoria Amme' Williams, PTA

• Skilled Nursing Facility in Crescent City, FL
• Providers in Crescent City, FL by specialty
• Skilled Nursing Facility in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 12, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.