Healthcare Provider Details

I. General information

NPI: 1942817804
Provider Name (Legal Business Name): LA VISTA HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2020
Last Update Date: 09/20/2021
Certification Date: 09/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 GRAND AVE STE L
DIAMOND BAR CA
91765-4172
US

IV. Provider business mailing address

1111 GRAND AVE STE L
DIAMOND BAR CA
91765-4172
US

V. Phone/Fax

Practice location:
  • Phone: 909-551-0205
  • Fax: 909-345-7084
Mailing address:
  • Phone: 909-551-0205
  • Fax: 909-345-7084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: MELISSA A TREVELLINE
Title or Position: CEO
Credential: M.D.
Phone: 724-462-3975