Provider Demographics
NPI:1093324725
Name:BUENA VISTA HOSPICE
Entity Type:Organization
Organization Name:BUENA VISTA HOSPICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:MIKITARIAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:818-736-5555
Mailing Address - Street 1:225 E BROADWAY STE B116C
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1008
Mailing Address - Country:US
Mailing Address - Phone:818-736-5555
Mailing Address - Fax:
Practice Address - Street 1:225 E BROADWAY STE B116C
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-1008
Practice Address - Country:US
Practice Address - Phone:818-536-7311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-29
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based