Provider Demographics
NPI:1548722283
Name:GRAND PAVILION, LLC
Entity type:Organization
Organization Name:GRAND PAVILION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:NOVOTNY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-313-0946
Mailing Address - Street 1:1213 HYLTON HEIGHTS RD STE 129
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502-2812
Mailing Address - Country:US
Mailing Address - Phone:785-313-0946
Mailing Address - Fax:
Practice Address - Street 1:4330 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64111-3340
Practice Address - Country:US
Practice Address - Phone:816-753-6800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-02
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility