MEDICARE: VISTA MARIA

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	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	43 01 052026	MI
2	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	43 01 032319	MI
3	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	43 01 036786	MI
4	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	43 01 070436	MI

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
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477639458
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VISTA MARIA

Provider Business Mailing Address
First Line	:	20651 W WARREN ST
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48127-2622
Country	:	US
Telephone Number	:	313-271-3050
Fax Number	:	313-336-3460

Provider Business Practice Location Address
First Line	:	20651 W WARREN AVE
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48127-2622
Country	:	US
Telephone Number	:	313-271-3050
Fax Number	:	313-336-3460

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	MR. EARL GODDIN
Credential	:
Telephone Number	:	313-271-3050

Provider Enumeration Date	:	10/31/2006
Last Update Date	:	04/07/2008

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Directions to “VISTA MARIA ” Practice Location

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