Provider Demographics
NPI:1568794535
Name:MOUNTAIN VISTA MEDICAL CENTER
Entity Type:Organization
Organization Name:MOUNTAIN VISTA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:480-283-7534
Mailing Address - Street 1:1301 S CRISMON RD
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-3767
Mailing Address - Country:US
Mailing Address - Phone:480-358-6100
Mailing Address - Fax:
Practice Address - Street 1:1301 S CRISMON RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-3767
Practice Address - Country:US
Practice Address - Phone:480-358-6100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-02
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3524282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NR1301XHospitalsGeneral Acute Care HospitalRural