Provider Demographics
NPI:1083338826
Name:MONTE VISTA MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:MONTE VISTA MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO/SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUTISTA
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:909-230-0101
Mailing Address - Street 1:9655 MONTE VISTA AVE STE 405
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-2238
Mailing Address - Country:US
Mailing Address - Phone:909-230-0101
Mailing Address - Fax:909-445-1122
Practice Address - Street 1:9655 MONTE VISTA AVE STE 405
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-2238
Practice Address - Country:US
Practice Address - Phone:909-230-0101
Practice Address - Fax:909-445-1122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty