Basic Information
Provider Information | |||||||||
NPI: | 1356852636 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PARADISE OAKS YOUTH SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6060 SUNRISE VISTA DR STE 2100 | ||||||||
Address2: |   | ||||||||
City: | CITRUS HEIGHTS | ||||||||
State: | CA | ||||||||
PostalCode: | 956107068 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9169676253 | ||||||||
FaxNumber: | 9169679413 | ||||||||
Practice Location | |||||||||
Address1: | 7331 HAZEL AVE | ||||||||
Address2: |   | ||||||||
City: | ORANGEVALE | ||||||||
State: | CA | ||||||||
PostalCode: | 956622440 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9169676253 | ||||||||
FaxNumber: | 9169679413 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/13/2017 | ||||||||
LastUpdateDate: | 07/17/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | THOMPSON | ||||||||
AuthorizedOfficialFirstName: | JENNIFER | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | QUALITY ASSURANCE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 9169676253 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | 347006002 | CA | Y |   | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |   |
No ID Information.