Healthcare Provider Details

I. General information

NPI: 1609826916
Provider Name (Legal Business Name): VISTA EMERGENCY PHYSICIANS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 12/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1015 E ROOSEVELT AVE EMERGENCY DEPARTMENT
GRANTS NM
87020-2117
US

IV. Provider business mailing address

13737 NOEL RD STE 1600
DALLAS TX
75240-1331
US

V. Phone/Fax

Practice location:
  • Phone: 973-251-1132
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KATHY KONDAS
Title or Position: OFFICER
Credential:
Phone: 973-251-1132