Provider Demographics
NPI:1508871989
Name:ALTA VISTA HEALTHCARE, LP
Entity Type:Organization
Organization Name:ALTA VISTA HEALTHCARE, LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:NATHANIEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:MANGUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-692-6666
Mailing Address - Street 1:5445 LA SIERRA DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4139
Mailing Address - Country:US
Mailing Address - Phone:214-692-6666
Mailing Address - Fax:214-692-6670
Practice Address - Street 1:1123 N MAIN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-4740
Practice Address - Country:US
Practice Address - Phone:210-822-6323
Practice Address - Fax:210-822-6356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1038107225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty