Provider Demographics
NPI:1164192316
Name:INDIAN RIVER PARADISE LLC
Entity Type:Organization
Organization Name:INDIAN RIVER PARADISE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MOSTAFA
Authorized Official - Middle Name:S
Authorized Official - Last Name:HASSAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:914-373-8098
Mailing Address - Street 1:2721 SE NORTH LOOKOUT BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34984-6108
Mailing Address - Country:US
Mailing Address - Phone:914-373-8098
Mailing Address - Fax:
Practice Address - Street 1:1275 N BANANA RIVER DR
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-5757
Practice Address - Country:US
Practice Address - Phone:914-373-8098
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-19
Last Update Date:2021-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility