Healthcare Provider Details

I. General information

NPI: 1487651121
Provider Name (Legal Business Name): BUENA VISTA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 03/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 BUENA VISTA DR
COLVILLE WA
99114-8676
US

IV. Provider business mailing address

151 BUENA VISTA DR
COLVILLE WA
99114-8676
US

V. Phone/Fax

Practice location:
  • Phone: 509-684-4539
  • Fax: 509-685-0582
Mailing address:
  • Phone: 509-684-4539
  • Fax: 509-684-6013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberBH 1023
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH 1244
License Number StateWA

VIII. Authorized Official

Name: LORRI CARTER
Title or Position: ADMINISTRATOR
Credential:
Phone: 509-684-4539