Provider Demographics
NPI:1790819282
Name:PARADISE MEDICAL ENTERPRISES
Entity Type:Organization
Organization Name:PARADISE MEDICAL ENTERPRISES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:EGIDIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-474-6300
Mailing Address - Street 1:2881 S VALLEY VW
Mailing Address - Street 2:SUITE 15
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-0100
Mailing Address - Country:US
Mailing Address - Phone:702-474-6300
Mailing Address - Fax:702-974-0108
Practice Address - Street 1:2881 S VALLEY VIEW
Practice Address - Street 2:SUITE 15
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-0100
Practice Address - Country:US
Practice Address - Phone:702-474-6300
Practice Address - Fax:702-974-0108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVM07-02190-1-080989207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV33031Medicare ID - Type UnspecifiedPROVIDER NUMBER