Provider Demographics
NPI:1972672137
Name:VISTA WEST HEALTH CENTER LP
Entity Type:Organization
Organization Name:VISTA WEST HEALTH CENTER LP
Other - Org Name:VISTA WEST HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALOYSIUS
Authorized Official - Middle Name:IFEANYI
Authorized Official - Last Name:UDEZE,
Authorized Official - Suffix:
Authorized Official - Credentials:BSC, DC, IDE, DABDA
Authorized Official - Phone:310-390-9293
Mailing Address - Street 1:11012 CHANERA AVE
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90303-2427
Mailing Address - Country:US
Mailing Address - Phone:310-390-9293
Mailing Address - Fax:323-820-1718
Practice Address - Street 1:12613 VENICE BLVD.
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066
Practice Address - Country:US
Practice Address - Phone:310-390-9293
Practice Address - Fax:323-820-1718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24645111NR0400X, 111NX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No111NX0100XChiropractic ProvidersChiropractorOccupational HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC24645OtherPROVIDERS PIN#
CAZZZ64099ZOtherBLUE SHIELD OF CA GRP#
CAU80414Medicare UPIN
CAZZZ64099ZOtherBLUE SHIELD OF CA GRP#
CAWDC24645BMedicare ID - Type UnspecifiedMEDICARE PPIN#