Organization
VISTA PEM PROVIDERS, LLC
Active
Other names
Sandra O'neal Institute
Organization subpart
No
Provider details
NPI number
Authorized official
LAURA KASSA (SR VICE PRESIDENT)
(904) 515-0362
Entity
Organization
Contact information
Practice address
5072 W PLANO PKWY, SUITE 190, PLANO, TX 75093-4476
(469) 362-6909
Mailing address
PO BOX 678282, DALLAS, TX 75267-8282
(469) 362-6909
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
—
—
261QR0200X
Radiology Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
282161301
—
TX
01
—
FTN041
MEDICARE PTAN
—
Enumeration date
05/07/2010
Last updated
04/06/2022
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