MEDICARE: VISTA DEL MAR CHILD AND FAMILY SVC.

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	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility

General Provider Information

NPI Number	:	1992243380
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VISTA DEL MAR CHILD AND FAMILY SVC.

Provider Business Mailing Address
First Line	:	3200 MOTOR AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-3710
Country	:	US
Telephone Number	:	310-836-1223
Fax Number	:	310-204-1405

Provider Business Practice Location Address
First Line	:	3321 EDITH ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-4736
Country	:	US
Telephone Number	:	310-836-1223
Fax Number	:	310-204-1405

Authorized Official
Title or Position	:	DIRECTOR QUALITY, STANDARDS AND COM
Name	:	CHERYL CARRINGTON
Credential	:
Telephone Number	:	310-836-1223

Provider Enumeration Date	:	02/06/2017
Last Update Date	:	03/01/2022

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