Healthcare Provider Details

I. General information

NPI: 1942206305
Provider Name (Legal Business Name): VISTA PACIFICA ENTERPRISES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3662 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: 951-274-4696
Mailing address:
  • Phone: 951-682-4833
  • Fax: 951-682-1503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateCA

VIII. Authorized Official

Name: MS. CHERYL B JUMONVILLE
Title or Position: EXECUTIVE VICE PRESIDENT
Credential:
Phone: 951-682-4833