Provider Demographics
NPI:1013067214
Name:VISTA IMAGING ASSOCIATES SC
Entity Type:Organization
Organization Name:VISTA IMAGING ASSOCIATES SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:
Authorized Official - Last Name:PULLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:309-363-4660
Mailing Address - Street 1:PO BOX 8453
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60197-8453
Mailing Address - Country:US
Mailing Address - Phone:309-363-4660
Mailing Address - Fax:
Practice Address - Street 1:1324 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085-2161
Practice Address - Country:US
Practice Address - Phone:847-360-4189
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CL1755Medicare PIN