Provider Demographics
NPI:1366427734
Name:PARADISE FAMILY HEALTH CENTER
Entity type:Organization
Organization Name:PARADISE FAMILY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BLANCA
Authorized Official - Middle Name:I
Authorized Official - Last Name:FRESNO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-475-4575
Mailing Address - Street 1:4364 BONITA RD
Mailing Address - Street 2:PB #467
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91902-1421
Mailing Address - Country:US
Mailing Address - Phone:619-475-4575
Mailing Address - Fax:
Practice Address - Street 1:655 EUCLID AVE
Practice Address - Street 2:SUITE #207
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-2957
Practice Address - Country:US
Practice Address - Phone:619-475-4575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-08
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0068530Medicaid