Provider Demographics
NPI:1336161785
Name:PARADISE MEDICAL SUPPLY, INC.
Entity Type:Organization
Organization Name:PARADISE MEDICAL SUPPLY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:MYRNA
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-633-7423
Mailing Address - Street 1:352 SAN CLAUDIO ST. , PMB 274
Mailing Address - Street 2:URB. SAGRADO CORAZON
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00926-4143
Mailing Address - Country:US
Mailing Address - Phone:787-633-7423
Mailing Address - Fax:
Practice Address - Street 1:809 MOLUCAS STREET
Practice Address - Street 2:COUNTRY CLUB
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00924-1701
Practice Address - Country:US
Practice Address - Phone:787-633-7423
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR4308950001332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR4308950001Medicare NSC