Provider Demographics
NPI:1245526029
Name:CANYON VISTA HEALTHCARE MEDICAL CORPORATION
Entity type:Organization
Organization Name:CANYON VISTA HEALTHCARE MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:MCINTYRE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:626-296-3181
Mailing Address - Street 1:2319 E WASHINGTON BLVD
Mailing Address - Street 2:SUITE ONE
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91104-1945
Mailing Address - Country:US
Mailing Address - Phone:626-296-3181
Mailing Address - Fax:
Practice Address - Street 1:2319 E WASHINGTON BLVD
Practice Address - Street 2:SUITE ONE
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91104-1945
Practice Address - Country:US
Practice Address - Phone:626-296-3181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-21
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29828261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care