Provider Demographics
NPI:1477639458
Name:VISTA MARIA
Entity Type:Organization
Organization Name:VISTA MARIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:EARL
Authorized Official - Middle Name:
Authorized Official - Last Name:GODDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-271-3050
Mailing Address - Street 1:20651 W WARREN ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-2622
Mailing Address - Country:US
Mailing Address - Phone:313-271-3050
Mailing Address - Fax:313-336-3460
Practice Address - Street 1:20651 W WARREN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-2622
Practice Address - Country:US
Practice Address - Phone:313-271-3050
Practice Address - Fax:313-336-3460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43 01 052026322D00000X
MI43 01 032319322D00000X
MI43 01 070436322D00000X
MI43 01 036786322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3241311Medicaid
MI4512114Medicaid
MI4652830Medicaid
MI4646898Medicaid