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General NPI Number Information
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NPI Number | 1891920724
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Entity Type | Organization
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Legal Business Name | PARADISE 2 PRP LLC
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Dates
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Enumeration Date | 05/21/2009
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Last Update Date | 05/21/2009
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Provider Practice Location Address
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Address Line | 7902 BELAIR RD SUITE 4
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City | NOTTINGHAM
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State | MD
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Zip | 21236-3707
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Country | US
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Telephone | 443-691-8522
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Fax | 410-325-1642
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Provider Business Mailing Address
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Address Line | 7902 BELAIR RD SUITE 4
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City | NOTTINGHAM
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State | MD
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Zip | 21236-3707
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Country | US
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Telephone | 443-691-8522
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Fax | 410-325-1642
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | MR. IGOR CHERNYAKHOVSKY
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Credential |
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Telephone | 443-691-8522
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 23093
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License Number State | MD
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