Healthcare Provider Details

I. General information

NPI: 1427209618
Provider Name (Legal Business Name): PARADAISE MEDICAL OFFICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2008
Last Update Date: 10/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 PARADISE RD STE E
MODESTO CA
95351-3163
US

IV. Provider business mailing address

401 PARADISE RD STE E
MODESTO CA
95351-3163
US

V. Phone/Fax

Practice location:
  • Phone: 209-558-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name: MICHEAL GORMAN
Title or Position: ATTENDING PHYSICIAN
Credential: M.D.
Phone: 209-558-4000