Provider Demographics
NPI:1194866277
Name:VISTA SOUTH ASSISTING LIVING
Entity Type:Organization
Organization Name:VISTA SOUTH ASSISTING LIVING
Other - Org Name:VISTA SOUTH ASSISTED LIVING
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-435-3808
Mailing Address - Street 1:1010 E SOUTHERN AVE BLDG 2
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85040-5108
Mailing Address - Country:US
Mailing Address - Phone:602-435-3808
Mailing Address - Fax:602-276-1854
Practice Address - Street 1:1010 E SOUTHERN AVE BLDG 2
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85040-5108
Practice Address - Country:US
Practice Address - Phone:602-435-3808
Practice Address - Fax:602-276-1854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALH5881310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ174413Medicaid