Provider Demographics
NPI:1366588444
Name:ALTA VISTA HEALTHCARE CENTER
Entity type:Organization
Organization Name:ALTA VISTA HEALTHCARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COOWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHIL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOHART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-822-6323
Mailing Address - Street 1:PO BOX 600324
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75360-0324
Mailing Address - Country:US
Mailing Address - Phone:210-822-6323
Mailing Address - Fax:210-822-6356
Practice Address - Street 1:1123 N MAIN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-4740
Practice Address - Country:US
Practice Address - Phone:210-822-6323
Practice Address - Fax:210-822-6356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15980101YP2500X
TX1038107225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty