Provider Demographics
NPI:1619107240
Name:VISTA COMMUNITY CLINIC
Entity Type:Organization
Organization Name:VISTA COMMUNITY CLINIC
Other - Org Name:VISTA COMMUNITY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANNINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-631-5000
Mailing Address - Street 1:134 GRAPEVINE RD
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-4004
Mailing Address - Country:US
Mailing Address - Phone:760-631-5030
Mailing Address - Fax:760-414-3754
Practice Address - Street 1:134 GRAPEVINE RD
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-4004
Practice Address - Country:US
Practice Address - Phone:760-631-5030
Practice Address - Fax:760-414-3754
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-16
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X
CA499513336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2120987OtherPK
CA1851300123Medicaid