Provider Demographics
NPI:1245743889
Name:VIDA MEDICAL GROUP PA
Entity Type:Organization
Organization Name:VIDA MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:BETANCOURT JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:786-470-4471
Mailing Address - Street 1:26847 S DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-7524
Mailing Address - Country:US
Mailing Address - Phone:786-470-4471
Mailing Address - Fax:305-489-0183
Practice Address - Street 1:26847 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-7524
Practice Address - Country:US
Practice Address - Phone:786-470-4471
Practice Address - Fax:305-489-0183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-06
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9263134363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty