Provider Demographics
NPI:1952726390
Name:VISTA ADULT SERVICES ORGANIZATION
Entity Type:Organization
Organization Name:VISTA ADULT SERVICES ORGANIZATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-583-5102
Mailing Address - Street 1:24 NORTHEAST DR
Mailing Address - Street 2:
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-2732
Mailing Address - Country:US
Mailing Address - Phone:717-835-1115
Mailing Address - Fax:
Practice Address - Street 1:24 NORTHEAST DR
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2732
Practice Address - Country:US
Practice Address - Phone:717-835-1115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-21
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0Medicaid