Provider Demographics
NPI:1003845942
Name:VIDA VITAL LLC
Entity Type:Organization
Organization Name:VIDA VITAL LLC
Other - Org Name:VIDA MEDICAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YAILEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BENGOCHEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-256-9747
Mailing Address - Street 1:1490 W 68TH ST
Mailing Address - Street 2:201
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-4590
Mailing Address - Country:US
Mailing Address - Phone:786-256-9747
Mailing Address - Fax:
Practice Address - Street 1:1490 W 68TH ST
Practice Address - Street 2:201
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33014-4590
Practice Address - Country:US
Practice Address - Phone:786-256-9747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHCC7020173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHCC7020OtherHEALTH DEPT LICENSE
FLHCC7020OtherHEALTH DEPT LICENSE