Provider Demographics
NPI:1902504699
Name:VISTA REJUVENATION & WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:VISTA REJUVENATION & WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:USMAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:LIGALI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-438-8943
Mailing Address - Street 1:11301 RICHMOND AVE STE K109
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77082-5549
Mailing Address - Country:US
Mailing Address - Phone:832-328-5350
Mailing Address - Fax:
Practice Address - Street 1:11301 RICHMOND AVE STE K109
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77082-5549
Practice Address - Country:US
Practice Address - Phone:832-328-5350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty