MEDICARE: MONTE NIDO LAKE VISTA, 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	320800000X	Mental Illness Community Based Residential Treatment Facility	550000662	CA

General Provider Information

NPI Number	:	1730357930
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MONTE NIDO LAKE VISTA, LLC

Provider Business Mailing Address
First Line	:	6100 SW 76TH ST
Second Line	:
City	:	SOUTH MIAMI
State	:	FL
Zip	:	33143-5002
Country	:	US
Telephone Number	:	305-663-1876
Fax Number	:	786-359-4485

Provider Business Practice Location Address
First Line	:	28855 LAKE VISTA DR
Second Line	:
City	:	AGOURA HILLS
State	:	CA
Zip	:	91301-2801
Country	:	US
Telephone Number	:	818-338-7890
Fax Number	:	818-338-7897

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	MIKE BAGLEY
Credential	:
Telephone Number	:	305-663-1876

Provider Enumeration Date	:	02/11/2008
Last Update Date	:	05/27/2020

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