Healthcare Provider Details

I. General information

NPI: 1730836412
Provider Name (Legal Business Name): MOUNT VISTA HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2022
Last Update Date: 03/03/2022
Certification Date: 03/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 TIMS AVE
HARRISON AR
72601-2229
US

IV. Provider business mailing address

362 E KENNEDY BLVD
LAKEWOOD NJ
08701-1434
US

V. Phone/Fax

Practice location:
  • Phone: 870-741-7667
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: JACOB TAUB
Title or Position: AUTHORIZED REP
Credential:
Phone: 718-838-1500