Provider Demographics
NPI:1497210629
Name:PARADISE GROUP HOME LLC
Entity type:Organization
Organization Name:PARADISE GROUP HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JERRILYN
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:ADKISSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-471-3770
Mailing Address - Street 1:208 N INGRAM RD
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-5233
Mailing Address - Country:US
Mailing Address - Phone:573-471-3770
Mailing Address - Fax:
Practice Address - Street 1:121 FRONT STREET
Practice Address - Street 2:
Practice Address - City:RISCO
Practice Address - State:MO
Practice Address - Zip Code:63874
Practice Address - Country:US
Practice Address - Phone:573-394-5020
Practice Address - Fax:573-394-5022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-01
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service