Provider Demographics
NPI:1194195164
Name:COLLEGE VISTA, LLC
Entity type:Organization
Organization Name:COLLEGE VISTA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF BUSINESS AFFAIRS
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSAKOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-577-3880
Mailing Address - Street 1:3050 SATURN STREET
Mailing Address - Street 2:STE 201
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821
Mailing Address - Country:US
Mailing Address - Phone:714-577-3880
Mailing Address - Fax:714-577-3895
Practice Address - Street 1:4681 NORTH EAGLE ROCK BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041
Practice Address - Country:US
Practice Address - Phone:323-257-8151
Practice Address - Fax:323-257-2187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-02
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA970000044314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA555030Medicare Oscar/Certification