Healthcare Provider Details

I. General information

NPI: 1972672137
Provider Name (Legal Business Name): VISTA WEST HEALTH CENTER LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 03/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12613 VENICE BLVD.
LOS ANGELES CA
90066
US

IV. Provider business mailing address

11012 CHANERA AVE
INGLEWOOD CA
90303-2427
US

V. Phone/Fax

Practice location:
  • Phone: 310-390-9293
  • Fax: 323-820-1718
Mailing address:
  • Phone: 310-390-9293
  • Fax: 323-820-1718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberDC24645
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code111NX0100X
TaxonomyOccupational Health Chiropractor
License NumberDC24645
License Number StateCA

VIII. Authorized Official

Name: DR. ALOYSIUS IFEANYI UDEZE,
Title or Position: DIRECTOR PRESIDENT
Credential: BSC, DC, IDE, DABDA.
Phone: 310-390-9293