1326125402 NPI number — VISTA CARE, LLC

Table of content: (NPI 1326125402)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326125402 NPI number — VISTA CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VISTA CARE, LLC
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:
6
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:
1326125402
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1093
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST MICHAELS
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86511-1093
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-674-3818
Provider Business Mailing Address Fax Number:
928-674-5814

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
HWY 254 - 1 MILE SE FROM CHAPTER HOUSE
Provider Second Line Business Practice Location Address:
WESTSIDE - PINK BLDG/GRAY TOP
Provider Business Practice Location Address City Name:
ST. MICHAELS
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-810-3707
Provider Business Practice Location Address Fax Number:
928-810-3713
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BALCH
Authorized Official First Name:
BROOKE
Authorized Official Middle Name:
E
Authorized Official Title or Position:
CFO OF THREE SPRINGS, INC.
Authorized Official Telephone Number:
256-880-3339

Provider Taxonomy Codes

  • Taxonomy code: 261QM0850X , with the licence number:  NAVAJO NATION WAIVER , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 261QM0855X , with the licence number: NAVAJO NATION WAIVER , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 688640 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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