Provider Demographics
NPI:1952177115
Name:PARADISE LODGE LLC
Entity Type:Organization
Organization Name:PARADISE LODGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:K
Authorized Official - Last Name:AMPONSAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-595-0112
Mailing Address - Street 1:43858 W LINDGREN DR
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85138-5523
Mailing Address - Country:US
Mailing Address - Phone:224-595-0112
Mailing Address - Fax:
Practice Address - Street 1:18860 N MARICOPA RD
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85139-1817
Practice Address - Country:US
Practice Address - Phone:122-459-5011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty