Provider Demographics
NPI:1366529414
Name:VISTA CARE, LLC
Entity type:Organization
Organization Name:VISTA CARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO OF THREE SPRINGS INC.
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:PO BOX 1820
Mailing Address - Street 2:
Mailing Address - City:CHINLE
Mailing Address - State:AZ
Mailing Address - Zip Code:86503-1820
Mailing Address - Country:US
Mailing Address - Phone:928-674-3818
Mailing Address - Fax:928-674-5814
Practice Address - Street 1:NAVAJO ROUTE 7
Practice Address - Street 2:WESTSIDE PRESBYTERIAN CHURCH
Practice Address - City:CHINLE
Practice Address - State:AZ
Practice Address - Zip Code:86503
Practice Address - Country:US
Practice Address - Phone:928-674-3818
Practice Address - Fax:928-674-5814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZNAVAJO NATION WAIVER261QM0850X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Not Answered261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ611807Medicaid