Provider Demographics
NPI:1447357728
Name:VISTA CARE LLC
Entity type:Organization
Organization Name:VISTA CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/CFO, PRESIDENT OF THREE SPRINGS
Authorized Official - Prefix:MR
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:E
Authorized Official - Last Name:BALCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-880-3339
Mailing Address - Street 1:4120 E RAMSEY RD
Mailing Address - Street 2:
Mailing Address - City:HEREFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85615-8917
Mailing Address - Country:US
Mailing Address - Phone:520-378-6466
Mailing Address - Fax:520-378-6553
Practice Address - Street 1:4120 E RAMSEY RD
Practice Address - Street 2:
Practice Address - City:HEREFORD
Practice Address - State:AZ
Practice Address - Zip Code:85615-8917
Practice Address - Country:US
Practice Address - Phone:520-378-6466
Practice Address - Fax:520-378-6553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH 1920322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ593104Medicaid