Provider Demographics
NPI:1356326409
Name:VISTA CLINICAL DIAGNOSTICS LLC
Entity Type:Organization
Organization Name:VISTA CLINICAL DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVIAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:SANTANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-536-9270
Mailing Address - Street 1:4290 S HWY 27
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-8066
Mailing Address - Country:US
Mailing Address - Phone:352-536-9270
Mailing Address - Fax:352-536-9279
Practice Address - Street 1:4290 S HWY 27
Practice Address - Street 2:SUITE 201
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-8066
Practice Address - Country:US
Practice Address - Phone:352-536-9270
Practice Address - Fax:352-536-9279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL800027066291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL800018794OtherSTATE LICENSE NUMBER
FL800018794OtherSTATE LICENSE NUMBER