Healthcare Provider Details

I. General information

NPI: 1932587946
Provider Name (Legal Business Name): VISTA DEL SOL LTC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2015
Last Update Date: 06/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11620 W WASHINGTON BLVD
LOS ANGELES CA
90066-5916
US

IV. Provider business mailing address

11620 W WASHINGTON BLVD
LOS ANGELES CA
90066-5916
US

V. Phone/Fax

Practice location:
  • Phone: 310-390-9045
  • Fax: 310-391-8738
Mailing address:
  • Phone: 310-390-9045
  • Fax: 310-391-8738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number910000037
License Number StateCA

VIII. Authorized Official

Name: DOV EDWARD JACOBS
Title or Position: PRESIDENT
Credential:
Phone: 310-390-9045