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General NPI Number Information
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NPI Number | 1942817804
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Entity Type | Organization
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Legal Business Name | LA VISTA HEALTH
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Dates
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Enumeration Date | 09/24/2020
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Last Update Date | 09/20/2021
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Provider Practice Location Address
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Address Line | 1111 GRAND AVE STE L
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City | DIAMOND BAR
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State | CA
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Zip | 91765-4172
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Country | US
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Telephone | 909-551-0205
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Fax | 909-345-7084
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Provider Business Mailing Address
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Address Line | 1111 GRAND AVE STE L
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City | DIAMOND BAR
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State | CA
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Zip | 91765-4172
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Country | US
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Telephone | 909-551-0205
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Fax | 909-345-7084
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Authorized Official
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Title or Position | CEO
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Name | MELISSA A TREVELLINE
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Credential | M.D.
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Telephone | 724-462-3975
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology 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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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