Provider Demographics
NPI:1073050043
Name:CLINIC VIDA, LLC
Entity Type:Organization
Organization Name:CLINIC VIDA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURE PHYSICIAN, DOCTOR OF OR
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:BARCUS
Authorized Official - Suffix:
Authorized Official - Credentials:LAP, DOM, BSPH, MOA
Authorized Official - Phone:941-879-7388
Mailing Address - Street 1:73 S PALM AVE
Mailing Address - Street 2:SUITE 223
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34236-5638
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:73 S PALM AVE
Practice Address - Street 2:SUITE 223
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34236-5638
Practice Address - Country:US
Practice Address - Phone:941-879-7388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-27
Last Update Date:2017-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP3476171100000X, 174H00000X, 175L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
No175L00000XOther Service ProvidersHomeopathGroup - Multi-Specialty