MEDICARE: VISTA GUIDANCE CENTERS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	360023AN	CA
2	251S00000X	Community/Behavioral Health Agency	240000192	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093845422
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VISTA GUIDANCE CENTERS, INC.

Provider Business Mailing Address
First Line	:	PO BOX 7369
Second Line	:
City	:	REDLANDS
State	:	CA
Zip	:	92375-0369
Country	:	US
Telephone Number	:	909-335-7067
Fax Number	:	909-792-2045

Provider Business Practice Location Address
First Line	:	34324 YUCAIPA BLVD
Second Line	:	SUITE B-D
City	:	YUCAIPA
State	:	CA
Zip	:	92399-2496
Country	:	US
Telephone Number	:	909-790-1300
Fax Number	:	909-797-9687

Authorized Official
Title or Position	:	GERNERAL MANAGER
Name	:	KATHLEEN DARLING
Credential	:
Telephone Number	:	606-335-7067

Provider Enumeration Date	:	03/06/2007
Last Update Date	:	06/01/2009

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