MEDICARE: PARADISE RETREAT ASSISTED LIVING FACILITY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QH0100X	Health Service Clinic/Center	AL12180	FL
2	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1225385214
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARADISE RETREAT ASSISTED LIVING FACILITY LLC

Provider Business Mailing Address
First Line	:	5626 SOUTEL DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32219-3772
Country	:	US
Telephone Number	:	904-551-5046
Fax Number	:	904-551-5058

Provider Business Practice Location Address
First Line	:	5626 SOUTEL DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32219-3772
Country	:	US
Telephone Number	:	904-551-5046
Fax Number	:	904-551-5058

Authorized Official
Title or Position	:	OWNER/ ADMINISTRATOR
Name	:	WARRENRINA LA'TARA HENDERSON
Credential	:
Telephone Number	:	904-551-5046

Provider Enumeration Date	:	08/08/2012
Last Update Date	:	08/08/2012

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