Provider Demographics
NPI:1093386450
Name:PARADISE LODGE LLC
Entity Type:Organization
Organization Name:PARADISE LODGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:KWESI
Authorized Official - Last Name:AMPONSAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-595-0112
Mailing Address - Street 1:43858 W LINDGREN DR
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85138-5523
Mailing Address - Country:US
Mailing Address - Phone:520-246-5998
Mailing Address - Fax:520-246-5994
Practice Address - Street 1:43858 W LINDGREN DR
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85138-5523
Practice Address - Country:US
Practice Address - Phone:520-246-5998
Practice Address - Fax:520-246-5994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility