Provider Demographics
NPI:1164119970
Name:CLINICA NUEVA VIDA MEDICAL INC
Entity Type:Organization
Organization Name:CLINICA NUEVA VIDA MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:HERMAN
Authorized Official - Middle Name:FRICKE
Authorized Official - Last Name:CARRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-847-1007
Mailing Address - Street 1:10970 SHERMAN WAY STE 114
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-1003
Mailing Address - Country:US
Mailing Address - Phone:818-847-1007
Mailing Address - Fax:
Practice Address - Street 1:10970 SHERMAN WAY STE 114
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-1003
Practice Address - Country:US
Practice Address - Phone:818-847-1007
Practice Address - Fax:818-847-1154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-20
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care