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Organization
VISTA MARIA
Active
Organization
VISTA MARIA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. EARL GODDIN (CHIEF FINANCIAL OFFICER)
(313) 271-3050
Entity
Organization
Contact information
Practice address
20651 W WARREN AVE, DEARBORN HEIGHTS, MI 48127-2622
(313) 271-3050
(313) 336-3460
Mailing address
20651 W WARREN ST, DEARBORN HEIGHTS, MI 48127-2622
(313) 271-3050
(313) 336-3460
Taxonomy
Speciality
Code
Description
License number
State
322D00000X
Emotionally Disturbed Childrens' Residential Treatment Facility
43 01 032319
MI
322D00000X
Emotionally Disturbed Childrens' Residential Treatment Facility
43 01 036786
MI
322D00000X
Emotionally Disturbed Childrens' Residential Treatment Facility
43 01 052026
MI
322D00000X
Emotionally Disturbed Childrens' Residential Treatment Facility
Primary
43 01 070436
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
3241311
—
MI
05
—
4512114
—
MI
05
—
4646898
—
MI
05
—
4652830
—
MI
Enumeration date
10/31/2006
Last updated
04/07/2008
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