MEDICARE: VISTA BEHAVIORAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1952991374
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VISTA BEHAVIORAL LLC

Provider Business Mailing Address
First Line	:	18022 LAKE ENCINO DR
Second Line	:
City	:	ENCINO
State	:	CA
Zip	:	91316-4428
Country	:	US
Telephone Number	:	973-277-5359
Fax Number	:

Provider Business Practice Location Address
First Line	:	18022 LAKE ENCINO DR
Second Line	:
City	:	ENCINO
State	:	CA
Zip	:	91316-4428
Country	:	US
Telephone Number	:	973-277-5359
Fax Number	:

Authorized Official
Title or Position	:	ACCOUNT MANAGER
Name	:	BRYAN MATTHEW DISIMONE
Credential	:
Telephone Number	:	973-277-5359

Provider Enumeration Date	:	01/20/2021
Last Update Date	:	01/20/2021

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