Healthcare Provider Details

I. General information

NPI: 1235111006
Provider Name (Legal Business Name): PARADISE MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 01/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6470 PENTZ RD SUITE A
PARADISE CA
95969-3674
US

IV. Provider business mailing address

6470 PENTZ RD SUITE A
PARADISE CA
95969-3674
US

V. Phone/Fax

Practice location:
  • Phone: 530-872-6650
  • Fax: 530-872-6653
Mailing address:
  • Phone: 530-872-6650
  • Fax: 530-872-6653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: RICHARD E. THORP
Title or Position: PRESIDENT/CEO
Credential: M.D.
Phone: 530-872-6650