Provider Demographics
NPI:1649725144
Name:PARADISE VILLA SENIOR CARE,LLC
Entity type:Organization
Organization Name:PARADISE VILLA SENIOR CARE,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KONAH
Authorized Official - Middle Name:JOSEPHINE
Authorized Official - Last Name:DOLO
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN, PHN
Authorized Official - Phone:704-236-7133
Mailing Address - Street 1:836 SAN SIMEON DR
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94518-2245
Mailing Address - Country:US
Mailing Address - Phone:925-446-6651
Mailing Address - Fax:
Practice Address - Street 1:836 SAN SIMEON DR
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94518-2245
Practice Address - Country:US
Practice Address - Phone:925-446-6651
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA079200312310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility