=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609826916
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VISTA EMERGENCY PHYSICIANS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2006
-----------------------------------------------------
Last Update Date | 12/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1015 E ROOSEVELT AVE EMERGENCY DEPARTMENT
-----------------------------------------------------
City | GRANTS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87020-2117
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-251-1132
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13737 NOEL RD STE 1600
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75240-1331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER
-----------------------------------------------------
Name | KATHY KONDAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-251-1132
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------