Provider Demographics
NPI:1912901489
Name:PARADISE WEST MEDICAL
Entity Type:Organization
Organization Name:PARADISE WEST MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARISEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:787-833-1870
Mailing Address - Street 1:PO BOX 582
Mailing Address - Street 2:
Mailing Address - City:MAYAGUEZ
Mailing Address - State:PR
Mailing Address - Zip Code:00681-0582
Mailing Address - Country:US
Mailing Address - Phone:787-833-1870
Mailing Address - Fax:787-833-1870
Practice Address - Street 1:CALLE TENERIFE
Practice Address - Street 2:# 11
Practice Address - City:MAYAGUEZ
Practice Address - State:PR
Practice Address - Zip Code:00680-1474
Practice Address - Country:US
Practice Address - Phone:787-833-1870
Practice Address - Fax:787-833-1870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5140390001302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR5140390001Medicare ID - Type Unspecified