1215430210 NPI number — TRAVEL PARADISE VACATIONS

Table of content: (NPI 1215430210)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215430210 NPI number — TRAVEL PARADISE VACATIONS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRAVEL PARADISE VACATIONS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215430210
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1459 WILD BLOSSOM WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CASTLE ROCK
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80104-7635
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-333-9220
Provider Business Mailing Address Fax Number:
303-997-9810

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1459 WILD BLOSSOM WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CASTLE ROCK
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80104-7635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-333-9220
Provider Business Practice Location Address Fax Number:
303-997-9810
Provider Enumeration Date:
03/15/2018

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
LEQUESOR
Authorized Official Middle Name:
LYNETTE
Authorized Official Title or Position:
CHIEF EXECTIVE DIRECTOR/ MANAGER
Authorized Official Telephone Number:
225-270-5055

Provider Taxonomy Codes

  • Taxonomy code: 343900000X , with the licence number:  062770743 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: G240420 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com