Healthcare Provider Details

I. General information

NPI: 1013625391
Provider Name (Legal Business Name): PACIFIC VISTAS TELEHEALTH INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2022
Last Update Date: 11/07/2022
Certification Date: 11/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 WEST GRAVES
MONTEREY PARK CA
91754
US

IV. Provider business mailing address

2000 WELLINGTON ROAD
LOS ANGELES CA
90016
US

V. Phone/Fax

Practice location:
  • Phone: 917-653-4625
  • Fax: 517-212-9671
Mailing address:
  • Phone: 917-653-4625
  • Fax: 517-212-9671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: JEREMY D. WILLIAMS MD
Title or Position: PRESIDENT
Credential: MD
Phone: 917-653-4625