Provider Demographics
NPI:1336832948
Name:PARADIGM SAN FRANCISCO MARINA
Entity Type:Organization
Organization Name:PARADIGM SAN FRANCISCO MARINA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-457-9008
Mailing Address - Street 1:12424 WILSHIRE BLVD STE 800
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-1035
Mailing Address - Country:US
Mailing Address - Phone:310-457-6300
Mailing Address - Fax:
Practice Address - Street 1:135 MARINA BLVD
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-4224
Practice Address - Country:US
Practice Address - Phone:310-457-6300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PARADIGM TREATMENT CENTERS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-05-30
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility