Healthcare Provider Details

I. General information

NPI: 1699194969
Provider Name (Legal Business Name): NAZARETH VISTA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2014
Last Update Date: 04/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1041 HILL ST
BELMONT CA
94002-2317
US

IV. Provider business mailing address

1041 HILL ST
BELMONT CA
94002-2317
US

V. Phone/Fax

Practice location:
  • Phone: 650-591-7181
  • Fax: 650-591-1857
Mailing address:
  • Phone: 650-591-7181
  • Fax: 650-591-1857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number220000010
License Number StateCA

VIII. Authorized Official

Name: JULIE MAMMAD
Title or Position: ADMINISTRATOR
Credential:
Phone: 650-591-7181