Healthcare Provider Details

I. General information

NPI: 1962568352
Provider Name (Legal Business Name): VISTA GRANDE INN, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 09/18/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 EAST HOSPITAL DRIVE
CORTEZ CO
81321
US

IV. Provider business mailing address

680 EAST HOSPITAL DRIVE
CORTEZ CO
81321
US

V. Phone/Fax

Practice location:
  • Phone: 970-564-1122
  • Fax: 970-564-1131
Mailing address:
  • Phone: 970-564-1122
  • Fax: 970-564-1131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

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

# 1
Identifier89157231
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer

VIII. Authorized Official

Name: MRS. LUCIANA SINGER
Title or Position: MANAGEMENT
Credential:
Phone: 970-516-1404