Provider Demographics
NPI:1548793896
Name:PARADISE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:PARADISE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, PT
Authorized Official - Prefix:DR
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:MICHELE
Authorized Official - Last Name:AMBRIZ
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, OMPT
Authorized Official - Phone:956-455-3107
Mailing Address - Street 1:39785 PALM DR
Mailing Address - Street 2:
Mailing Address - City:BAYVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:78566-4479
Mailing Address - Country:US
Mailing Address - Phone:956-455-3107
Mailing Address - Fax:
Practice Address - Street 1:112 E QUEEN ISABELLA
Practice Address - Street 2:SUITE 1
Practice Address - City:PORT ISABEL
Practice Address - State:TX
Practice Address - Zip Code:78578
Practice Address - Country:US
Practice Address - Phone:956-455-3107
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-04
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1189508225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX206938701Medicaid
TXTX-B105970Medicare PIN