Healthcare Provider Details

I. General information

NPI: 1588734164
Provider Name (Legal Business Name): VISTA PACIFICA ENTERPRISES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 05/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3674 PACIFIC AVE
RIVERSIDE CA
92509-1948
US

IV. Provider business mailing address

3674 PACIFIC AVE
RIVERSIDE CA
92509-1948
US

V. Phone/Fax

Practice location:
  • Phone: 951-682-4833
  • Fax: 951-682-1503
Mailing address:
  • Phone: 951-682-4833
  • Fax: 951-682-1503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number250000118
License Number StateCA

VIII. Authorized Official

Name: MR. ALLAN ENGELAUF
Title or Position: ADMINISTRATOR
Credential:
Phone: 951-682-4833