Provider Demographics
NPI:1841664620
Name:VISTA GRANDE INN, INC
Entity type:Organization
Organization Name:VISTA GRANDE INN, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGEMENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LUCIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:SINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-516-1404
Mailing Address - Street 1:680 E HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-6200
Mailing Address - Country:US
Mailing Address - Phone:970-564-1122
Mailing Address - Fax:970-564-1131
Practice Address - Street 1:680 E HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-6200
Practice Address - Country:US
Practice Address - Phone:970-564-1122
Practice Address - Fax:970-564-1131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO12208086Medicaid