Provider Demographics
NPI:1912659178
Name:PEORIA VISTA CARE LLC
Entity Type:Organization
Organization Name:PEORIA VISTA CARE LLC
Other - Org Name:PEORIA VISTA CARE LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:POLUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-481-8746
Mailing Address - Street 1:10430 W ROYAL PALM RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85345-7537
Mailing Address - Country:US
Mailing Address - Phone:623-440-5391
Mailing Address - Fax:
Practice Address - Street 1:10430 W ROYAL PALM RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-7537
Practice Address - Country:US
Practice Address - Phone:623-440-5391
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-19
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility