Provider Demographics
NPI:1003111246
Name:VISTA REHAB CENTER CORP
Entity Type:Organization
Organization Name:VISTA REHAB CENTER CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIANKA
Authorized Official - Middle Name:
Authorized Official - Last Name:DE PAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-459-2637
Mailing Address - Street 1:175 FONTAINEBLEAU BLVD STE 1G2
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-4511
Mailing Address - Country:US
Mailing Address - Phone:786-459-2637
Mailing Address - Fax:
Practice Address - Street 1:175 FONTAINEBLEAU BLVD STE 1G2
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33172-4511
Practice Address - Country:US
Practice Address - Phone:786-459-2637
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-19
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 47653261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA 47653OtherPHYSICAL THERAPY