Provider Demographics
NPI:1902185994
Name:AVISTA SENIOR LIVING VITA BELLA, LLC
Entity Type:Organization
Organization Name:AVISTA SENIOR LIVING VITA BELLA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:KRISTOPHER
Authorized Official - Middle Name:L
Authorized Official - Last Name:WOOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-628-5900
Mailing Address - Street 1:1725 S COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-6003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:248 N MACDONALD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-6651
Practice Address - Country:US
Practice Address - Phone:480-964-6685
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAL8507CMedicaid