Provider Demographics
NPI:1982235057
Name:TRAVEL PARADISE VACATIONS
Entity Type:Organization
Organization Name:TRAVEL PARADISE VACATIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/ CHIEF EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LEQUESOR
Authorized Official - Middle Name:LYNETTE
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:PASTOR
Authorized Official - Phone:225-333-9220
Mailing Address - Street 1:1459 WILD BLOSSOM WAY
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-7635
Mailing Address - Country:US
Mailing Address - Phone:225-333-9220
Mailing Address - Fax:
Practice Address - Street 1:1459 WILD BLOSSOM WAY
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-7635
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRAVEL PARADISE VACATIONS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker
No3416L0300XTransportation ServicesAmbulanceLand Transport
No344600000XTransportation ServicesTaxi
No347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1215430210Medicaid