Healthcare Provider Details

I. General information

NPI: 1609184522
Provider Name (Legal Business Name): PARADISE RESIDENTIAL CARE FACILITIES FOR THE ELDERLY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2010
Last Update Date: 09/14/2010
Certification Date: PARADISE RESIDENTIAL CARE FACILITIES FOR THE ELDERLY PO BOX 503916 SAN DIEGO CA 92150 1581 SYCAMORE DR FALLBROOK CA 92028
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1581 SYCAMORE DR
FALLBROOK CA
92028-9100
US

IV. Provider business mailing address

PO BOX 503916
SAN DIEGO CA
92150-3916
US

V. Phone/Fax

Practice location:
  • Phone: 760-728-1900
  • Fax: 760-728-2225
Mailing address:
  • Phone: 760-728-1900
  • Fax: 858-672-5655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number374601799
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyHospice Care, Community Based
License Number374601799
License Number StateCA

VIII. Authorized Official

Name: MS. FATTANEH MOGHADAM-YEKTA
Title or Position: LICENSED ADMINISTRATOR
Credential:
Phone: 858-342-9104