Basic Information
Provider Information | |||||||||
NPI: | 1902863418 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AURORA VISTA DEL MAR, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AURORA VISTA DEL MAR, LLC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 801 SENECA ST | ||||||||
Address2: |   | ||||||||
City: | VENTURA | ||||||||
State: | CA | ||||||||
PostalCode: | 930011411 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8056536434 | ||||||||
FaxNumber: | 8056410429 | ||||||||
Practice Location | |||||||||
Address1: | 801 SENECA ST | ||||||||
Address2: |   | ||||||||
City: | VENTURA | ||||||||
State: | CA | ||||||||
PostalCode: | 930011411 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8056536434 | ||||||||
FaxNumber: | 8056410429 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/27/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KREBSBACH | ||||||||
AuthorizedOfficialFirstName: | MAYLA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 8056536434 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X |   |   | Y |   | Hospitals | Psychiatric Hospital |   |
ID Information
ID | Type | State | Issuer | Description | HSP44077H | 05 | CA |   | MEDICAID | HSP34077H | 05 | CA |   | MEDICAID | HSM34077H | 05 | CA |   | MEDICAID |