Healthcare Provider Details

I. General information

NPI: 1740858679
Provider Name (Legal Business Name): ALTA VISTA CONGREGATE LIVING, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2021
Last Update Date: 07/09/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13880 PROCTOR AVE
LA PUENTE CA
91746-2529
US

IV. Provider business mailing address

13880 PROCTOR AVE
LA PUENTE CA
91746-2529
US

V. Phone/Fax

Practice location:
  • Phone: 626-373-7619
  • Fax: 888-385-1958
Mailing address:
  • Phone: 626-373-7619
  • Fax: 888-385-1958

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: NICOLE STINSON
Title or Position: VICE PRESIDENT
Credential:
Phone: 626-373-7619