Provider Demographics
NPI:1851940308
Name:VISTA PRADO INC
Entity Type:Organization
Organization Name:VISTA PRADO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TEDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:GODFREY
Authorized Official - Suffix:
Authorized Official - Credentials:LVN
Authorized Official - Phone:707-853-5133
Mailing Address - Street 1:1331 ALABAMA ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-4602
Mailing Address - Country:US
Mailing Address - Phone:707-530-9283
Mailing Address - Fax:
Practice Address - Street 1:105 POWER DR
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2529
Practice Address - Country:US
Practice Address - Phone:707-643-7617
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-07
Last Update Date:2019-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)