Healthcare Provider Details

I. General information

NPI: 1720502370
Provider Name (Legal Business Name): VISTA HEALTHCARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2017
Last Update Date: 11/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

556 TREJO ST STE B
REXBURG ID
83440-2626
US

IV. Provider business mailing address

556 TREJO STREET SUITE B
REXBURG ID
83440-2625
US

V. Phone/Fax

Practice location:
  • Phone: 208-351-6981
  • Fax:
Mailing address:
  • Phone: 208-351-6981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberNP-914A
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP-914A
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP-914A
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP-914A
License Number StateID
# 5
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberNP-914A
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: RACHELLE JONES
Title or Position: PRESIDENT
Credential: FNP-C
Phone: 208-881-0902