Provider Demographics
NPI:1760469878
Name:VILLA VISTA, INC.
Entity Type:Organization
Organization Name:VILLA VISTA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-644-3331
Mailing Address - Street 1:1197 VILLA VISTA CIRCLE
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:MN
Mailing Address - Zip Code:55726-0098
Mailing Address - Country:US
Mailing Address - Phone:218-644-3331
Mailing Address - Fax:218-644-3505
Practice Address - Street 1:1197 VILLA VISTA CIRCLE
Practice Address - Street 2:
Practice Address - City:CROMWELL
Practice Address - State:MN
Practice Address - Zip Code:55726-0098
Practice Address - Country:US
Practice Address - Phone:218-644-3331
Practice Address - Fax:218-644-3505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN330912313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN24E483Medicare ID - Type Unspecified