=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073999470
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VISTA MONTANA SENIOR LIVING INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2015
-----------------------------------------------------
Last Update Date | 08/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 155 N GIRARD ST
-----------------------------------------------------
City | HEMET
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92544-4624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-658-2274
-----------------------------------------------------
Fax | 951-765-2025
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 155 N GIRARD ST
-----------------------------------------------------
City | HEMET
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92544-4624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-658-2274
-----------------------------------------------------
Fax | 951-765-2025
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | JAMES BENDER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-430-2994
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 336426330
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------