Healthcare Provider Details

I. General information

NPI: 1477639458
Provider Name (Legal Business Name): VISTA MARIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 04/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20651 W WARREN AVE
DEARBORN HEIGHTS MI
48127-2622
US

IV. Provider business mailing address

20651 W WARREN ST
DEARBORN HEIGHTS MI
48127-2622
US

V. Phone/Fax

Practice location:
  • Phone: 313-271-3050
  • Fax: 313-336-3460
Mailing address:
  • Phone: 313-271-3050
  • Fax: 313-336-3460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number43 01 052026
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number43 01 032319
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number43 01 036786
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number43 01 070436
License Number StateMI

VIII. Authorized Official

Name: MR. EARL GODDIN
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 313-271-3050