Basic Information
| Provider Information | |||||||||
| NPI: | 1225359367 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VISTA PEM PROVIDERS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 678282 | ||||||||
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| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752678282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724791115 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5072 W PLANO PKWY | ||||||||
| Address2: | SUITE 190 | ||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750934476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9724791115 | ||||||||
| FaxNumber: | 9724791118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2010 | ||||||||
| LastUpdateDate: | 01/19/2018 | ||||||||
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| AuthorizedOfficialLastName: | HADLEY | ||||||||
| AuthorizedOfficialFirstName: | CLERISSA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF NETWORK DEVELOPMENT | ||||||||
| AuthorizedOfficialTelephone: | 9722157410 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QX0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Oncology | 261QR0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Radiology |
No ID Information.