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General NPI Number Information
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NPI Number | 1164192316
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Entity Type | Organization
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Legal Business Name | INDIAN RIVER PARADISE LLC
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Dates
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Enumeration Date | 09/19/2021
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Last Update Date | 09/19/2021
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Provider Practice Location Address
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Address Line | 1275 N BANANA RIVER DR
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City | MERRITT ISLAND
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State | FL
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Zip | 32952-5757
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Country | US
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Telephone | 914-373-8098
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Fax |
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Provider Business Mailing Address
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Address Line | 2721 SE NORTH LOOKOUT BLVD
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34984-6108
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Country | US
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Telephone | 914-373-8098
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MOSTAFA S HASSAN
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Credential | MD
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Telephone | 914-373-8098
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number |
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License Number State |
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