Provider Demographics
NPI:1811180565
Name:PARADISE PINES LLC
Entity type:Organization
Organization Name:PARADISE PINES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER FOR PARADISE PINES LLC
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:ZANDSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:BSN RN
Authorized Official - Phone:605-342-2385
Mailing Address - Street 1:429 ALTA VISTA DRIVE
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701
Mailing Address - Country:US
Mailing Address - Phone:605-342-2385
Mailing Address - Fax:
Practice Address - Street 1:4110 WINFIELD STREET
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701
Practice Address - Country:US
Practice Address - Phone:605-348-2596
Practice Address - Fax:605-342-4119
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PARADISE PINES LLC DBA MORNINGSTAR ALC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD51260310400000X
SD47202310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9571202Medicaid