Provider Demographics
NPI:1275767410
Name:VALLEY VISTA CARE HOME
Entity Type:Organization
Organization Name:VALLEY VISTA CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FIBIA
Authorized Official - Middle Name:O
Authorized Official - Last Name:COMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-434-5567
Mailing Address - Street 1:2206 W SPUR DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-5752
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2206 W SPUR DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85085-5752
Practice Address - Country:US
Practice Address - Phone:623-434-5567
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-02
Last Update Date:2009-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZALH6406305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization