Provider Demographics
NPI:1689868010
Name:PRIME HEALTHCARE PARADISE VALLEY HOSPITAL
Entity Type:Organization
Organization Name:PRIME HEALTHCARE PARADISE VALLEY HOSPITAL
Other - Org Name:PRIME ALLY PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:HANLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-470-4233
Mailing Address - Street 1:330 MOSS ST
Mailing Address - Street 2:490 EMORY, IMPERIAL BEACH, CA. 91932
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-2005
Mailing Address - Country:US
Mailing Address - Phone:619-585-4228
Mailing Address - Fax:
Practice Address - Street 1:2001 RIMBEY AVENUE
Practice Address - Street 2:CLASS ROOM #27
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-3099
Practice Address - Country:US
Practice Address - Phone:619-628-3541
Practice Address - Fax:619-628-3589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37JW101YM0800X
CA090000086283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No283Q00000XHospitalsPsychiatric HospitalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA37JWOtherCOUNTY OF SAN DIEGO