Provider Demographics
NPI:1710132758
Name:PARADIS ISLES WELLNESS, LLC
Entity Type:Organization
Organization Name:PARADIS ISLES WELLNESS, LLC
Other - Org Name:PROHEALTH CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:BOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-536-5330
Mailing Address - Street 1:2812 COOPERSMITH CT
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-5019
Mailing Address - Country:US
Mailing Address - Phone:317-536-5330
Mailing Address - Fax:317-219-3083
Practice Address - Street 1:2812 COOPERSMITH CT
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-5019
Practice Address - Country:US
Practice Address - Phone:317-536-5330
Practice Address - Fax:317-219-3083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN8919475900OtherDRIVER LICENSE