Provider Demographics
NPI:1225385214
Name:PARADISE RETREAT ASSISTED LIVING FACILITY LLC
Entity Type:Organization
Organization Name:PARADISE RETREAT ASSISTED LIVING FACILITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:WARRENRINA
Authorized Official - Middle Name:LA'TARA
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-551-5046
Mailing Address - Street 1:5626 SOUTEL DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32219-3772
Mailing Address - Country:US
Mailing Address - Phone:904-551-5046
Mailing Address - Fax:904-551-5058
Practice Address - Street 1:5626 SOUTEL DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32219-3772
Practice Address - Country:US
Practice Address - Phone:904-551-5046
Practice Address - Fax:904-551-5058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-08
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QH0100X
FLAL12180261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service