=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104458090
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARADISE CREEK HOMES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2020
-----------------------------------------------------
Last Update Date | 02/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 42714 N MURPHY AVE
-----------------------------------------------------
City | SAN TAN VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85140-9813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-718-9939
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10511 E CORBIN AVE
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-331-4160
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | CLOVIS HERMANN LAWIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 202-718-9939
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------