Provider Demographics
NPI:1285750901
Name:PARADISE WOUND HEALING PROFESSIONALS, PLLC
Entity type:Organization
Organization Name:PARADISE WOUND HEALING PROFESSIONALS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:C
Authorized Official - Last Name:TOWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-758-4667
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-0189
Mailing Address - Country:US
Mailing Address - Phone:509-758-1119
Mailing Address - Fax:509-758-1140
Practice Address - Street 1:1119 HIGHLAND AVENUE
Practice Address - Street 2:SUITE 7
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2836
Practice Address - Country:US
Practice Address - Phone:509-758-1119
Practice Address - Fax:509-758-1140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602411261174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DJVB5OtherBLUE CROSS OF IDAHO
DJVB5OtherBLUE CROSS OF IDAHO
WA8808417Medicare PIN