Provider Demographics
NPI:1558369694
Name:VISTA SPECIALTY HOSPITAL OF SOUTHERN CALIFORNIA
Entity Type:Organization
Organization Name:VISTA SPECIALTY HOSPITAL OF SOUTHERN CALIFORNIA
Other - Org Name:VISTA SPECIALTY HOSPITAL OF SAN GABRIEL VALLEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGIONAL VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:FERRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-388-2700
Mailing Address - Street 1:14148 FRANCISQUITO AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-6120
Mailing Address - Country:US
Mailing Address - Phone:626-388-2700
Mailing Address - Fax:626-388-2720
Practice Address - Street 1:14148 FRANCISQUITO AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-6120
Practice Address - Country:US
Practice Address - Phone:626-388-2700
Practice Address - Fax:626-388-2720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHSP32045FMedicaid
CA05-2045Medicare ID - Type UnspecifiedLTAC PROVIDER NUMBER