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General NPI Number Information
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NPI Number | 1881945905
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Entity Type | Organization
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Legal Business Name | VISTA BEHAVIORAL HEALTH, INC
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Dates
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Enumeration Date | 09/28/2012
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Last Update Date | 09/28/2012
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Provider Practice Location Address
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Address Line | 10630 TOWN CENTER DRIVE. STE 110
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730
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Country | US
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Telephone | 909-919-7727
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Fax |
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Provider Business Mailing Address
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Address Line | 10630 TOWN CENTER DRIVE STE 110
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730
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Country | US
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Telephone | 909-919-7727
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Fax | 909-191-2035
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Authorized Official
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Title or Position | PRESIDENT
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Name | OCHUKO GREGSON DIAMREYOU
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Credential | MD
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Telephone | 909-919-7727
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | A66432
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License Number State | CA
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