Basic Information
| Provider Information | |||||||||
| NPI: | 1407973514 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VISTA GUIDANCE CENTERS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | REDLANDS YUCAIPA GUIDANCE CLINIC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7369 | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923750369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093357067 | ||||||||
| FaxNumber: | 9097922045 | ||||||||
| Practice Location | |||||||||
| Address1: | 790 BEAUMONT AVE STE 210 | ||||||||
| Address2: | |||||||||
| City: | BEAUMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922235900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517697436 | ||||||||
| FaxNumber: | 9517697486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BORJA | ||||||||
| AuthorizedOfficialFirstName: | SONIA | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 9093357067 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 330070AN | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 3383 | 05 | CA | MEDICAID |