Basic Information
| Provider Information | |||||||||
| NPI: | 1477639458 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VISTA MARIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20651 W WARREN ST | ||||||||
| Address2: | |||||||||
| City: | DEARBORN HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481272622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132713050 | ||||||||
| FaxNumber: | 3133363460 | ||||||||
| Practice Location | |||||||||
| Address1: | 20651 W WARREN AVE | ||||||||
| Address2: | |||||||||
| City: | DEARBORN HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481272622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132713050 | ||||||||
| FaxNumber: | 3133363460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 04/07/2008 | ||||||||
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| AuthorizedOfficialLastName: | GODDIN | ||||||||
| AuthorizedOfficialFirstName: | EARL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3132713050 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | 43 01 052026 | MI | N | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children | 322D00000X | 43 01 032319 | MI | N | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children | 322D00000X | 43 01 036786 | MI | N | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children | 322D00000X | 43 01 070436 | MI | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
ID Information
| ID | Type | State | Issuer | Description | 3241311 | 05 | MI | MEDICAID | 4512114 | 05 | MI | MEDICAID | 4652830 | 05 | MI | MEDICAID | 4646898 | 05 | MI | MEDICAID |