MEDICARE: PARADISE AUTISM CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center

General Provider Information

NPI Number	:	1487381729
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARADISE AUTISM CENTER LLC

Provider Business Mailing Address
First Line	:	2722 PARK AVE # 116
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-1009
Country	:	US
Telephone Number	:	781-888-4563
Fax Number	:

Provider Business Practice Location Address
First Line	:	2722 PARK AVE # 116
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-1009
Country	:	US
Telephone Number	:	781-888-4563
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BAYDAN ALI MOHAMED
Credential	:
Telephone Number	:	781-888-4563

Provider Enumeration Date	:	08/05/2022
Last Update Date	:	08/05/2022

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