Basic Information
| Provider Information | |||||||||
| NPI: | 1194195164 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLLEGE VISTA, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COLLEGE VISTA CONVALESCENT HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3050 SATURN STREET | ||||||||
| Address2: | STE 201 | ||||||||
| City: | BREA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145773880 | ||||||||
| FaxNumber: | 7145773895 | ||||||||
| Practice Location | |||||||||
| Address1: | 4681 NORTH EAGLE ROCK BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232578151 | ||||||||
| FaxNumber: | 3232572187 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2015 | ||||||||
| LastUpdateDate: | 10/02/2015 | ||||||||
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| AuthorizedOfficialLastName: | RUSSAKOFF | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF BUSINESS AFFAIRS | ||||||||
| AuthorizedOfficialTelephone: | 7145773880 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 970000044 | CA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.