Provider Demographics
NPI:1326125402
Name:VISTA CARE, LLC
Entity Type:Organization
Organization Name:VISTA CARE, LLC
Other - Org Name:VISTA SPRINGS TRADITIONS - ST. MICHAELS
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO OF THREE SPRINGS, INC.
Authorized Official - Prefix:MR
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:E
Authorized Official - Last Name:BALCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-880-3339
Mailing Address - Street 1:PO BOX 1093
Mailing Address - Street 2:
Mailing Address - City:ST MICHAELS
Mailing Address - State:AZ
Mailing Address - Zip Code:86511-1093
Mailing Address - Country:US
Mailing Address - Phone:928-674-3818
Mailing Address - Fax:928-674-5814
Practice Address - Street 1:HWY 254 - 1 MILE SE FROM CHAPTER HOUSE
Practice Address - Street 2:WESTSIDE - PINK BLDG/GRAY TOP
Practice Address - City:ST. MICHAELS
Practice Address - State:AZ
Practice Address - Zip Code:86511
Practice Address - Country:US
Practice Address - Phone:928-810-3707
Practice Address - Fax:928-810-3713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZNAVAJO NATION WAIVER261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Not Answered261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ688640Medicaid