Healthcare Provider Details

I. General information

NPI: 1710132758
Provider Name (Legal Business Name): PARADIS ISLES WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2008
Last Update Date: 11/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2812 COOPERSMITH CT
INDIANAPOLIS IN
46268-5019
US

IV. Provider business mailing address

2812 COOPERSMITH CT
INDIANAPOLIS IN
46268-5019
US

V. Phone/Fax

Practice location:
  • Phone: 317-536-5330
  • Fax: 317-219-3083
Mailing address:
  • Phone: 317-536-5330
  • Fax: 317-219-3083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: MR. JAY WESLEY BOGAN
Title or Position: OWNER
Credential:
Phone: 317-536-5330