Provider Demographics
NPI:1881912335
Name:VISTA PEM PROVIDERS, LLC
Entity type:Organization
Organization Name:VISTA PEM PROVIDERS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:KASSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-515-0362
Mailing Address - Street 1:PO BOX 678282
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-8282
Mailing Address - Country:US
Mailing Address - Phone:469-362-6909
Mailing Address - Fax:
Practice Address - Street 1:5072 W PLANO PKWY
Practice Address - Street 2:SUITE 190
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-4476
Practice Address - Country:US
Practice Address - Phone:469-362-6909
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-07
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX282161301Medicaid
FTN041OtherMEDICARE PTAN