Provider Demographics
NPI:1497076277
Name:MAR VISTA HEALTH CENTER, INC
Entity Type:Organization
Organization Name:MAR VISTA HEALTH CENTER, INC
Other - Org Name:SINEL MEDICAL CORPORATION
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:HIGASHI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:310-391-2617
Mailing Address - Street 1:3030 SAWTELLE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-1408
Mailing Address - Country:US
Mailing Address - Phone:310-391-2617
Mailing Address - Fax:310-390-0868
Practice Address - Street 1:3030 SAWTELLE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-1408
Practice Address - Country:US
Practice Address - Phone:310-391-2617
Practice Address - Fax:310-390-0868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-16
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27775111N00000X
CADC27651111N00000X
CADC30839111N00000X
CAAC10834171100000X
CAAC3057171100000X
CAG65692208100000X
CAC51939208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACZ842AMedicare PIN
CA6422900001Medicare NSC