Provider Demographics
NPI:1417002320
Name:NUEVA VIDA MENTAL HEALTH CENTER
Entity Type:Organization
Organization Name:NUEVA VIDA MENTAL HEALTH CENTER
Other - Org Name:NUEVA VIDA BEHAVIORAL HEALTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GODRHAT
Authorized Official - Middle Name:P
Authorized Official - Last Name:SHOLEVAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-229-0956
Mailing Address - Street 1:618 W LEHIGH AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19133-2227
Mailing Address - Country:US
Mailing Address - Phone:215-229-8857
Mailing Address - Fax:215-229-0654
Practice Address - Street 1:618 W LEHIGH AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19133-2227
Practice Address - Country:US
Practice Address - Phone:215-229-8857
Practice Address - Fax:215-229-0654
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016954870003OtherPROMISE NUMBER