NPIMap

Organization Active NPI

Pavilion at Canal Fulton, LLC

Doing business as The Pavilion at Canal Fulton for Nursing and Rehabilitation, LLC

  • Skilled Nursing Facility
  • Canal Fulton, OH
National Provider Identifier
1396565214
Registry record updated Apr 2, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
Legal business name
PAVILION AT CANAL FULTON, LLC
Doing business as
The Pavilion at Canal Fulton for Nursing and Rehabilitation, LLC
Practice address
7055 High Mill Ave NW
Canal Fulton, OH 44614-9344
Phone
(330) 854-4545
NPI assigned
Oct 15, 2024
Last updated
Apr 2, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 2, 2025

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

Authorized official

Name
Kymberly Lavin
Title
Executive Assistant
Phone
(516) 865-1500

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X Primary

Addresses

Primary practice location

7055 High Mill Ave NW
Canal Fulton, OH 44614-9344

Mailing address

1 Valley Greens Dr
Valley Stream, NY 11581-3634
Phone (516) 865-1500

Other names 1

  • The Pavilion at Canal Fulton for Nursing and Rehabilitation, LLC Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20250714001054 OH Part A Provider - Skilled Nursing Facility 1456866037 Practice locations: Canal Fulton, OH

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1396565214. Details of each certification follow.

Skilled nursing facility certification: CCN 366271

Legal name
PAVILION AT CANAL FULTON LLC
Doing business as
THE PAVILION AT CANAL FULTON FOR NURSING AND REHABILITATION
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
May 13, 2003
Last certification
Jun 18, 2025
Beds
60
Ownership / control type
Corporation
Multi-facility organization
The Pavillion
Organization structure
LLCProprietary
Enrollment address
7055 High Mill Ave NW
Canal Fulton, OH 44614-9344
Nursing home name
THE PAVILION AT CANAL FULTON FOR NURSING AND REHABILITATION
Affiliated entity
THE PAVILION GROUP

Care Compare: Nursing home

Medicare Care Compare
Listed as
The Pavilion at Canal Fulton for Nursing and RehabCCN 366271 · All quality measures
Overall star rating
2 of 5
Health inspections
3 of 5
Staffing
1 of 5
Quality measures
4 of 5
Type
Medicare and Medicaid
Ownership
For profit - Corporation
Certified
May 13, 2003
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
6038.2 residents per day on average
Chain
The Pavilion Group6 facilities in the chain

Processed by Care Compare on Aug 1, 2026.

Laboratory certificates & supplier records

Derived by NPIMap

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

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
36D0724824Pavilion at Canal Fulton7055 High Mill Ave NW, Canal Fulton, OH 44614Certificate of waiverAug 31, 2026

National Provider Directory

National Provider Directory

Ownership & related parties

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.

NameRoleSinceShare
The Pavilion Managment Company LLC Organization, Valley Stream, NY LLC, Management services company Adp of the SNF Feb 6, 2025
Tyler Evans Individual 5% Or Greater Indirect Ownership Interest Feb 6, 2025 2%
Jyothi Gudla Individual Adp of the SNF Dec 16, 2024
Npnh1 LLC Organization, Miami Beach, FL LLC, Owned by another organization or individual 5% Or Greater Indirect Ownership Interest Dec 16, 2024 15%
Adp of the SNF Dec 16, 2024
Canal Group Holdings LLC Organization, Valley Stream, NY LLC, Holding company, Owned by another organization or individual 5% Or Greater Direct Ownership Interest Dec 16, 2024 100%
Operational/Managerial Control Dec 16, 2024
Ezra Birnbaum Individual 5% Or Greater Indirect Ownership Interest Dec 16, 2024 15%
Quality Healthcare Resources Organization, Lakewood, NJ LLC Adp of the SNF Feb 6, 2025
Bankwell Organization, New Canaan, CT Financial institution Adp of the SNF Feb 6, 2025
Acm Ashem Holdings, LLC Organization, Valley Stream, NY LLC, Holding company, Owned by another organization or individual 5% Or Greater Indirect Ownership Interest Dec 16, 2024 55.5%
Kenneth J Biros Individual Adp of the SNF Dec 16, 2024
Shaye Hirsch Individual 5% Or Greater Indirect Ownership Interest Dec 16, 2024 22.5%
Adp of the SNF Feb 6, 2025
Matthew Kodrin Individual Operational/Managerial Control Dec 16, 2024
Adp of the SNF Dec 16, 2024
Rafael Moerman Individual 5% Or Greater Indirect Ownership Interest Dec 16, 2024 55.5%
Operational/Managerial Control Dec 16, 2024
Managing Control - Governing BodyCeo Dec 16, 2024
High Mill Holdings LLC Organization, Canal Fulton, OH LLC, Holding company Adp of the SNF Dec 16, 2024
SHS Keren LLC Organization, Cedarhurst, NY LLC, Owned by another organization or individual 5% Or Greater Indirect Ownership Interest Dec 16, 2024 5%
Simcha Schonfeld Individual 5% Or Greater Indirect Ownership Interest Feb 6, 2025 22.5%
Adp of the SNF Feb 6, 2025

Owners & managing parties with NPI records 2

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

Facilities with the same owner 9

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

Affiliated clinicians 1

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

NPI Registry JSON

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

{
    "created_epoch": "1728950400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1743552000000",
    "number": "1396565214",
    "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": "7055 HIGH MILL AVE NW",
            "city": "CANAL FULTON",
            "state": "OH",
            "postal_code": "446149344",
            "telephone_number": "330-854-4545"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PAVILION AT CANAL FULTON, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-10-15",
        "last_updated": "2025-04-02",
        "certification_date": "2025-04-02",
        "status": "A",
        "authorized_official_last_name": "LAVIN",
        "authorized_official_first_name": "KYMBERLY",
        "authorized_official_title_or_position": "EXECUTIVE ASSISTANT",
        "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 Canal Fulton for Nursing and Rehabilitation, LLC",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "The Pavilion at Canal Fulton for Nursing and Rehabilitation, LLC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Canal Fulton, OH

Sources for this page

Verify at the official NPI Registry.