Provider Demographics
NPI:1437214970
Name:MIRA VISTA CORPORATION
Entity Type:Organization
Organization Name:MIRA VISTA CORPORATION
Other - Org Name:MIRA VISTA CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:HALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-424-1320
Mailing Address - Street 1:300 S 18TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4661
Mailing Address - Country:US
Mailing Address - Phone:360-424-1320
Mailing Address - Fax:360-848-1948
Practice Address - Street 1:300 S 18TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4661
Practice Address - Country:US
Practice Address - Phone:360-424-1320
Practice Address - Fax:360-848-1948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA957314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4195707Medicaid
WA505315Medicare ID - Type UnspecifiedMEDICARE PROVIDER #