Provider Demographics
NPI:1972024420
Name:BELLA VITA CONGREGATE LIVING, LLC
Entity Type:Organization
Organization Name:BELLA VITA CONGREGATE LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE ADMINISTRATOR/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SONYA
Authorized Official - Middle Name:LISETTE
Authorized Official - Last Name:HARRELL
Authorized Official - Suffix:
Authorized Official - Credentials:RN, ACNP-BC
Authorized Official - Phone:951-640-8170
Mailing Address - Street 1:17130 VAN BUREN BLVD # 134
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-5905
Mailing Address - Country:US
Mailing Address - Phone:951-800-8435
Mailing Address - Fax:951-429-7162
Practice Address - Street 1:16092 CONSTABLE RD
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-5664
Practice Address - Country:US
Practice Address - Phone:951-800-8435
Practice Address - Fax:951-429-7162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-05
Last Update Date:2017-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550003868313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility