Provider Demographics
NPI:1093844656
Name:BELLA VISTA MEDICAL GROUP IPA
Entity Type:Organization
Organization Name:BELLA VISTA MEDICAL GROUP IPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF MEDICAL AFFAIRS
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEAKTOR
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:818-702-0100
Mailing Address - Street 1:PO BOX 572066
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91357-2066
Mailing Address - Country:US
Mailing Address - Phone:818-702-0100
Mailing Address - Fax:818-702-9128
Practice Address - Street 1:6400 CANOGA AVE
Practice Address - Street 2:SUITE 163
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-2425
Practice Address - Country:US
Practice Address - Phone:818-702-0100
Practice Address - Fax:818-702-9128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization