Provider Demographics
NPI:1073246047
Name:VIDA WELLNESS
Entity Type:Organization
Organization Name:VIDA WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REBECA
Authorized Official - Middle Name:E
Authorized Official - Last Name:DAVILA
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, LMSW
Authorized Official - Phone:773-987-1357
Mailing Address - Street 1:822 CASS AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-1116
Mailing Address - Country:US
Mailing Address - Phone:773-987-1357
Mailing Address - Fax:616-414-8530
Practice Address - Street 1:3167 KALAMAZOO AVE SE STE 205
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-1475
Practice Address - Country:US
Practice Address - Phone:773-987-1357
Practice Address - Fax:616-414-8530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty