Provider Demographics
NPI:1710206958
Name:VISTA HOSPITAL OF SOUTH BAY, LP
Entity Type:Organization
Organization Name:VISTA HOSPITAL OF SOUTH BAY, LP
Other - Org Name:VISTA HOSPITAL OF SOUTH BAY - TRI-CITY CAMPUS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE-PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:C
Authorized Official - Last Name:FERRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-581-7272
Mailing Address - Street 1:1246 W 155TH ST
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-4011
Mailing Address - Country:US
Mailing Address - Phone:310-323-5330
Mailing Address - Fax:310-768-2265
Practice Address - Street 1:21530 PIONEER BLVD
Practice Address - Street 2:
Practice Address - City:HAWAIIAN GARDENS
Practice Address - State:CA
Practice Address - Zip Code:90716-2608
Practice Address - Country:US
Practice Address - Phone:562-860-4488
Practice Address - Fax:562-860-4489
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VISTA HEALTHCARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-27
Last Update Date:2010-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA930000037282E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282E00000XHospitalsLong Term Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHSP40456IMedicaid
CAHSP30456IMedicaid
CAHSP40456IMedicaid