Provider Demographics
NPI:1316017809
Name:NUEVA VIDA MEDICAL INC.
Entity Type:Organization
Organization Name:NUEVA VIDA MEDICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ISSAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAFAJA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-484-6444
Mailing Address - Street 1:1725 BEVERLY BLVD
Mailing Address - Street 2:STE 103
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-5401
Mailing Address - Country:US
Mailing Address - Phone:213-484-6444
Mailing Address - Fax:213-484-6555
Practice Address - Street 1:1725 BEVERLY BLVD
Practice Address - Street 2:STE 103
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-5401
Practice Address - Country:US
Practice Address - Phone:213-484-6444
Practice Address - Fax:213-484-6555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54280207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty