Provider Demographics
NPI:1083810790
Name:VISTA HEALTHCARE, LLC
Entity Type:Organization
Organization Name:VISTA HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:C
Authorized Official - Last Name:FERRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-581-7272
Mailing Address - Street 1:10841 WHITE OAK AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3811
Mailing Address - Country:US
Mailing Address - Phone:909-581-7272
Mailing Address - Fax:909-581-7277
Practice Address - Street 1:10841 WHITE OAK AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3811
Practice Address - Country:US
Practice Address - Phone:909-581-7272
Practice Address - Fax:909-581-7277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service