Provider Demographics
NPI:1164264420
Name:HERNANDEZ, PAUL (MANAGER)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:HERNANDEZ
Suffix:
Gender:M
Credentials:MANAGER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:685 W ROLLER COASTER RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-3817
Mailing Address - Country:US
Mailing Address - Phone:520-293-3404
Mailing Address - Fax:520-989-9885
Practice Address - Street 1:685 W ROLLER COASTER RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-3817
Practice Address - Country:US
Practice Address - Phone:520-293-3404
Practice Address - Fax:520-989-9885
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-08
Last Update Date:2024-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL0128H311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home