Provider Demographics
NPI:1053934984
Name:MONTE NIDO LAKE VISTA, LLC
Entity type:Organization
Organization Name:MONTE NIDO LAKE VISTA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:BAGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-663-1876
Mailing Address - Street 1:6100 SW 76TH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-5002
Mailing Address - Country:US
Mailing Address - Phone:305-663-1876
Mailing Address - Fax:305-663-1876
Practice Address - Street 1:1776 IVANHOE AVE
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-1954
Practice Address - Country:US
Practice Address - Phone:305-663-1876
Practice Address - Fax:786-359-4485
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MONTE NIDO LAKE VISTA, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-05-27
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness