Provider Demographics
NPI:1386800365
Name:MIRA VISTA ENTERPRISE, INC.
Entity type:Organization
Organization Name:MIRA VISTA ENTERPRISE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALEJANDRO
Authorized Official - Middle Name:NOBLEJAS
Authorized Official - Last Name:FLORES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-819-2349
Mailing Address - Street 1:12500 BELLA VINO DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76126-4930
Mailing Address - Country:US
Mailing Address - Phone:817-819-2349
Mailing Address - Fax:
Practice Address - Street 1:12500 BELLA VINO DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76126-4930
Practice Address - Country:US
Practice Address - Phone:817-819-2349
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-30
Last Update Date:2017-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health