Healthcare Provider Details

I. General information

NPI: 1972014041
Provider Name (Legal Business Name): PARADISE DETOX, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2017
Last Update Date: 06/04/2020
Certification Date: 06/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5935 JOEL LN
LA MESA CA
91942-4101
US

IV. Provider business mailing address

1515 NW 167TH ST STE 300
MIAMI FL
33169-5106
US

V. Phone/Fax

Practice location:
  • Phone: 855-756-2013
  • Fax:
Mailing address:
  • Phone: 786-923-3376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. ROBERT NIZNIK
Title or Position: CEO
Credential:
Phone: 855-756-2013