Provider Demographics
NPI:1407143464
Name:PRIMA VIDA MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:PRIMA VIDA MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELEANOR
Authorized Official - Middle Name:VERZOSA
Authorized Official - Last Name:AZURIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-923-8300
Mailing Address - Street 1:8706 IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90242-3906
Mailing Address - Country:US
Mailing Address - Phone:562-923-8300
Mailing Address - Fax:
Practice Address - Street 1:8706 IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90242-3906
Practice Address - Country:US
Practice Address - Phone:562-923-8300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-28
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66742261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1407143464Medicaid
CA1407143464Medicaid