Provider Demographics
NPI:1104317460
Name:PARADISE VALLEY ICF DDH INC
Entity type:Organization
Organization Name:PARADISE VALLEY ICF DDH INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ LICENSEE
Authorized Official - Prefix:
Authorized Official - First Name:NIMFA
Authorized Official - Middle Name:
Authorized Official - Last Name:PUNZALAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-655-3225
Mailing Address - Street 1:3313 EL PINOLE WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-7208
Mailing Address - Country:US
Mailing Address - Phone:707-655-3225
Mailing Address - Fax:707-652-5168
Practice Address - Street 1:3313 EL PINOLE WAY
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-7208
Practice Address - Country:US
Practice Address - Phone:707-655-3225
Practice Address - Fax:707-652-5168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA010000432310500000X
315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness