Provider Demographics
NPI:1568174241
Name:SPARADISE LLC
Entity Type:Organization
Organization Name:SPARADISE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEARWATER
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:360-606-1694
Mailing Address - Street 1:14602 NE FOURTH PLAIN BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-5080
Mailing Address - Country:US
Mailing Address - Phone:360-606-1694
Mailing Address - Fax:
Practice Address - Street 1:14602 NE FOURTH PLAIN BLVD STE A
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98682-5080
Practice Address - Country:US
Practice Address - Phone:608-928-1913
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty