Provider Demographics
NPI:1538506225
Name:WEST VISTA DEL LAGO INC.
Entity Type:Organization
Organization Name:WEST VISTA DEL LAGO INC.
Other - Org Name:WEST VISTA DEL LAGO INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:UNA
Authorized Official - Middle Name:W
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-762-6881
Mailing Address - Street 1:1077 WATERSIDE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:FL
Mailing Address - Zip Code:33327
Mailing Address - Country:US
Mailing Address - Phone:954-762-6881
Mailing Address - Fax:954-636-3254
Practice Address - Street 1:1077 WATERSIDE CIR
Practice Address - Street 2:1077 WATERSIDE CIR
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33327-2031
Practice Address - Country:US
Practice Address - Phone:954-762-6881
Practice Address - Fax:954-636-3254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-04
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10557310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL=========Medicaid