Healthcare Provider Details

I. General information

NPI: 1861715070
Provider Name (Legal Business Name): VISTA DEL MAR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2010
Last Update Date: 03/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 MOTOR AVE
LOS ANGELES CA
90034-3710
US

IV. Provider business mailing address

3200 MOTOR AVE
LOS ANGELES CA
90034-3710
US

V. Phone/Fax

Practice location:
  • Phone: 310-836-1223
  • Fax: 310-837-6647
Mailing address:
  • Phone: 310-836-1223
  • Fax: 310-837-6647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: CHRISTIAN M FLORES
Title or Position: FAMILY FACILITATOR
Credential: B.A.
Phone: 310-836-1223