Healthcare Provider Details

I. General information

NPI: 1295039055
Provider Name (Legal Business Name): SLH VISTA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2011
Last Update Date: 07/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 VISTA AVE
SAINT LOUIS MO
63110-2539
US

IV. Provider business mailing address

PO BOX 741286
ATLANTA GA
30374-1286
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-8000
  • Fax: 314-577-8003
Mailing address:
  • Phone: 314-577-8000
  • Fax: 314-577-8003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY ADAMS
Title or Position: SVP REGIONAL OPERATIONS, TENET
Credential:
Phone: 469-893-2563