MEDICARE: PARADISE TREATMENT SERVICES I 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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1639815467
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARADISE TREATMENT SERVICES I LLC

Provider Business Mailing Address
First Line	:	4530 E RAY RD STE 172
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85044-6099
Country	:	US
Telephone Number	:	202-718-9939
Fax Number	:

Provider Business Practice Location Address
First Line	:	4530 E RAY RD STE 172
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85044-6099
Country	:	US
Telephone Number	:	202-718-9939
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CLOVIS HERMANN LAWIN
Credential	:
Telephone Number	:	202-718-9939

Provider Enumeration Date	:	05/05/2022
Last Update Date	:	05/05/2022

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