Provider Demographics
NPI:1720349251
Name:CHRISTINA ELLIS DBA: PARADISE ADULT FOSTER CARE HOME
Entity type:Organization
Organization Name:CHRISTINA ELLIS DBA: PARADISE ADULT FOSTER CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ELLIS-LITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-760-8052
Mailing Address - Street 1:1356 SE 172ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-4702
Mailing Address - Country:US
Mailing Address - Phone:503-760-8052
Mailing Address - Fax:503-760-8052
Practice Address - Street 1:1356 SE 172ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-4702
Practice Address - Country:US
Practice Address - Phone:503-760-8052
Practice Address - Fax:503-760-8052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-31
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10714320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness