Provider Demographics
NPI:1225359367
Name:VISTA PEM PROVIDERS, LLC
Entity Type:Organization
Organization Name:VISTA PEM PROVIDERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF NETWORK DEVELOPMENT
Authorized Official - Prefix:
Authorized Official - First Name:CLERISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:HADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-215-7410
Mailing Address - Street 1:PO BOX 678282
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-8282
Mailing Address - Country:US
Mailing Address - Phone:972-479-1115
Mailing Address - Fax:
Practice Address - Street 1:5072 W PLANO PKWY
Practice Address - Street 2:SUITE 190
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-4476
Practice Address - Country:US
Practice Address - Phone:972-479-1115
Practice Address - Fax:972-479-1118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-11
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QX0200XAmbulatory Health Care FacilitiesClinic/CenterOncology