=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154534220
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VISTA HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10301 MAYO DR
-----------------------------------------------------
City | BARLING
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72923-1660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-459-5700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4253 N CROSSOVER RD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72703-4593
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MHPP
-----------------------------------------------------
Name | MR. JAMES MICHAEL WHITTAKER I
-----------------------------------------------------
Credential | MHPP
-----------------------------------------------------
Telephone | 479-494-4700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------