Provider Demographics
NPI:1710220850
Name:RESIDENCE AT PADDOCK PARK, INC (THE)
Entity Type:Organization
Organization Name:RESIDENCE AT PADDOCK PARK, INC (THE)
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-906-4676
Mailing Address - Street 1:14622 PADDOCK DR
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-7822
Mailing Address - Country:US
Mailing Address - Phone:561-791-2630
Mailing Address - Fax:561-333-0613
Practice Address - Street 1:14622 PADDOCK DR
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-7822
Practice Address - Country:US
Practice Address - Phone:561-791-2630
Practice Address - Fax:561-333-0613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11250/11737310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility