Healthcare Provider Details

I. General information

NPI: 1366251142
Provider Name (Legal Business Name): MESA VISTA HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2025
Last Update Date: 02/05/2025
Certification Date: 02/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 MESA DR
BOULDER CO
80304-3621
US

IV. Provider business mailing address

262 N UNIVERSITY AVE
FARMINGTON UT
84025-2975
US

V. Phone/Fax

Practice location:
  • Phone: 303-442-4037
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000
Identifier TypeOTHER
Identifier StateCO
Identifier IssuerRESPITE

VIII. Authorized Official

Name: JOHN MITCHELL
Title or Position: SECRETARY
Credential:
Phone: 949-331-4067