Provider Demographics
NPI:1275533929
Name:VISTA WOODS HEALTH ASSOCIATES LLC
Entity Type:Organization
Organization Name:VISTA WOODS HEALTH ASSOCIATES LLC
Other - Org Name:VISTA KNOLL SPECIALIZED CARE FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED AGENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SOON
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-540-1249
Mailing Address - Street 1:2000 WESTWOOD RD
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-5123
Mailing Address - Country:US
Mailing Address - Phone:760-630-2273
Mailing Address - Fax:760-630-0913
Practice Address - Street 1:2000 WESTWOOD RD
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-5123
Practice Address - Country:US
Practice Address - Phone:760-630-2273
Practice Address - Fax:760-630-0913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-22
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA080000353314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC555425HMedicaid
CA55-5425Medicare ID - Type Unspecified