Basic Information
| Provider Information | |||||||||
| NPI: | 1659509693 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VISTA DEL MAR - SPA 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3325 WILSHIRE BLVD | ||||||||
| Address2: | SUITE 915 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900101703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108361223 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3325 WILSHIRE BLVD | ||||||||
| Address2: | SUITE 915 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900101749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108361223 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2009 | ||||||||
| LastUpdateDate: | 06/03/2019 | ||||||||
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| AuthorizedOfficialLastName: | CARRINGTON | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR QUALITY STANDARDS AND COMP | ||||||||
| AuthorizedOfficialTelephone: | 3108361223 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.