Healthcare Provider Details

I. General information

NPI: 1396754875
Provider Name (Legal Business Name): MOUNTAIN VISTA HEALTH PARK, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 02/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 MT VISTA RD
DENTON NC
27239-8793
US

IV. Provider business mailing address

PO BOX 1547
DENTON NC
27239-1547
US

V. Phone/Fax

Practice location:
  • Phone: 336-859-2181
  • Fax: 336-859-4053
Mailing address:
  • Phone: 336-859-2181
  • Fax: 336-859-4053

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
Identifier3405196
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 2
Identifier3406191
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: MRS. KATHY B MCDONALD
Title or Position: ADMINISTRATOR
Credential:
Phone: 336-859-2181