Provider Demographics
NPI:1932508868
Name:PARADISE LAKE SENIOR CARE HOME, LLC
Entity Type:Organization
Organization Name:PARADISE LAKE SENIOR CARE HOME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AFH PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:FRIGILLANA
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN
Authorized Official - Phone:425-761-7739
Mailing Address - Street 1:10121 219TH ST SE
Mailing Address - Street 2:
Mailing Address - City:SNOHOMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98296-4941
Mailing Address - Country:US
Mailing Address - Phone:425-761-7739
Mailing Address - Fax:
Practice Address - Street 1:10121 219TH ST SE
Practice Address - Street 2:
Practice Address - City:SNOHOMISH
Practice Address - State:WA
Practice Address - Zip Code:98296-4941
Practice Address - Country:US
Practice Address - Phone:425-761-7739
Practice Address - Fax:360-668-5297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-15
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA751477311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA515305Medicaid