Provider Demographics
NPI:1164310496
Name:PAVILION PACE, LLC
Entity type:Organization
Organization Name:PAVILION PACE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GIBSON
Authorized Official - Middle Name:
Authorized Official - Last Name:ERHUNMWUNSE
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:240-346-7488
Mailing Address - Street 1:4115 ANNANDALE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-2583
Mailing Address - Country:US
Mailing Address - Phone:240-346-7488
Mailing Address - Fax:703-226-5604
Practice Address - Street 1:4115 ANNANDALE RD STE 100
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-2583
Practice Address - Country:US
Practice Address - Phone:240-346-7488
Practice Address - Fax:703-226-5604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-25
Last Update Date:2025-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization