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General NPI Number Information
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NPI Number | 1225385214
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Entity Type | Organization
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Legal Business Name | PARADISE RETREAT ASSISTED LIVING FACILITY LLC
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Dates
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Enumeration Date | 08/08/2012
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Last Update Date | 08/08/2012
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Provider Practice Location Address
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Address Line | 5626 SOUTEL DR
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City | JACKSONVILLE
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State | FL
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Zip | 32219-3772
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Country | US
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Telephone | 904-551-5046
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Fax | 904-551-5058
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Provider Business Mailing Address
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Address Line | 5626 SOUTEL DR
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City | JACKSONVILLE
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State | FL
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Zip | 32219-3772
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Country | US
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Telephone | 904-551-5046
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Fax | 904-551-5058
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Authorized Official
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Title or Position | OWNER/ ADMINISTRATOR
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Name | WARRENRINA LA'TARA HENDERSON
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Credential |
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Telephone | 904-551-5046
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | AL12180
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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