Healthcare Provider Details

I. General information

NPI: 1568088193
Provider Name (Legal Business Name): BUENA VISTA AL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2020
Last Update Date: 06/19/2020
Certification Date: 06/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1393 S BUENA VISTA ST
HEMET CA
92543-7660
US

IV. Provider business mailing address

8306 WILSHIRE BLVD # 135
BEVERLY HILLS CA
90211-2304
US

V. Phone/Fax

Practice location:
  • Phone: 951-658-5160
  • Fax:
Mailing address:
  • Phone: 310-435-0797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: RODDY RADNIA
Title or Position: MANAGER
Credential:
Phone: 310-435-0797