Provider Demographics
NPI:1598433781
Name:PINNACLE VISTA RESIDENTIAL LLC
Entity Type:Organization
Organization Name:PINNACLE VISTA RESIDENTIAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MONIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-334-1417
Mailing Address - Street 1:17510 W PINNACLE VISTA DR
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85387-1132
Mailing Address - Country:US
Mailing Address - Phone:480-334-1417
Mailing Address - Fax:
Practice Address - Street 1:17510 W PINNACLE VISTA DR
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85387-1132
Practice Address - Country:US
Practice Address - Phone:480-677-5988
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness