MEDICARE: BRIGHTER VISTAS, LLC

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	174400000X	Specialist		TX

General Provider Information

NPI Number	:	1407049521
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIGHTER VISTAS, LLC

Provider Business Mailing Address
First Line	:	18057 HWY. 105 WEST
Second Line	:	SUITE 220
City	:	MONTGOMERY
State	:	TX
Zip	:	77356
Country	:	US
Telephone Number	:	936-582-5620
Fax Number	:	936-582-5621

Provider Business Practice Location Address
First Line	:	18057 HIGHWAY 105 W
Second Line	:	SUITE 220
City	:	MONTGOMERY
State	:	TX
Zip	:	77356-5985
Country	:	US
Telephone Number	:	936-582-5620
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. VELDA DESADIER
Credential	:	M.ED., DIAGNOSTICIAN
Telephone Number	:	936-232-2907

Provider Enumeration Date	:	08/22/2007
Last Update Date	:	08/22/2007

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