Provider Demographics
NPI:1205416856
Name:VIDA COMMUNITY HEALTH CLINIC
Entity Type:Organization
Organization Name:VIDA COMMUNITY HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:DELICIO
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:786-209-3340
Mailing Address - Street 1:8200 NW 41ST ST
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-6205
Mailing Address - Country:US
Mailing Address - Phone:786-209-3340
Mailing Address - Fax:786-204-0692
Practice Address - Street 1:8200 NW 41ST ST
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-6205
Practice Address - Country:US
Practice Address - Phone:786-209-3340
Practice Address - Fax:786-204-0692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101151900Medicaid