Basic Information
| Provider Information | |||||||||
| NPI: | 1558369694 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VISTA SPECIALTY HOSPITAL OF SOUTHERN CALIFORNIA | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VISTA SPECIALTY HOSPITAL OF SAN GABRIEL VALLEY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14148 FRANCISQUITO AVE | ||||||||
| Address2: | |||||||||
| City: | BALDWIN PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917066120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263882700 | ||||||||
| FaxNumber: | 6263882720 | ||||||||
| Practice Location | |||||||||
| Address1: | 14148 FRANCISQUITO AVE | ||||||||
| Address2: | |||||||||
| City: | BALDWIN PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917066120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263882700 | ||||||||
| FaxNumber: | 6263882720 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FERRELL | ||||||||
| AuthorizedOfficialFirstName: | MARC | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6263882700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | HSP32045F | 05 | CA | MEDICAID |