Provider Demographics
NPI:1710997804
Name:MOUNTAIN VISTA HEALTH PARK, INC.
Entity Type:Organization
Organization Name:MOUNTAIN VISTA HEALTH PARK, INC.
Other - Org Name:MOUNTAIN VISTA HEALTH PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:B
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-859-2181
Mailing Address - Street 1:PO BOX 1547
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:NC
Mailing Address - Zip Code:27239-1547
Mailing Address - Country:US
Mailing Address - Phone:336-859-2181
Mailing Address - Fax:336-859-4053
Practice Address - Street 1:106 MT VISTA RD
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:NC
Practice Address - Zip Code:27239-8793
Practice Address - Country:US
Practice Address - Phone:336-859-2181
Practice Address - Fax:336-859-4053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0259311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7801373Medicaid