Provider Demographics
NPI:1699194969
Name:NAZARETH VISTA
Entity Type:Organization
Organization Name:NAZARETH VISTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAMMAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-591-7181
Mailing Address - Street 1:1041 HILL ST
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94002-2317
Mailing Address - Country:US
Mailing Address - Phone:650-591-7181
Mailing Address - Fax:650-591-1857
Practice Address - Street 1:1041 HILL ST
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:CA
Practice Address - Zip Code:94002-2317
Practice Address - Country:US
Practice Address - Phone:650-591-7181
Practice Address - Fax:650-591-1857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-15
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA220000010314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA220000038Medicare Oscar/Certification