Provider Demographics
NPI:1710387451
Name:MARDAV INC
Entity Type:Organization
Organization Name:MARDAV INC
Other - Org Name:PARAISO PRIMARY HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORENA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALDONADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:915-262-0457
Mailing Address - Street 1:3100 EDGEROCK DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79935-1526
Mailing Address - Country:US
Mailing Address - Phone:915-262-0457
Mailing Address - Fax:
Practice Address - Street 1:3105 N YARBROUGH DR STE 112
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-3164
Practice Address - Country:US
Practice Address - Phone:915-262-0457
Practice Address - Fax:915-262-0430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-29
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Single Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========Medicaid