Healthcare Provider Details

I. General information

NPI: 1538222138
Provider Name (Legal Business Name): NEW VISTA RECOVERY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 WARM SPRINGS RD
GLEN ELLEN CA
95442-8730
US

IV. Provider business mailing address

3020 WARM SPRINGS RD
GLEN ELLEN CA
95442-8730
US

V. Phone/Fax

Practice location:
  • Phone: 707-996-6716
  • Fax: 707-996-0609
Mailing address:
  • Phone: 707-996-6716
  • Fax: 707-996-0609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number490025AP
License Number StateCA

VIII. Authorized Official

Name: MR. JONATHAN FONG
Title or Position: DIRECTOR OF MANAGED CARE
Credential: MBA
Phone: 707-996-6716