Provider Demographics
NPI:1447797865
Name:VIDA MOBILE CLINIC
Entity Type:Organization
Organization Name:VIDA MOBILE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PA-C
Authorized Official - Prefix:
Authorized Official - First Name:ANA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-425-9437
Mailing Address - Street 1:16750 INDEX ST
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-3606
Mailing Address - Country:US
Mailing Address - Phone:818-425-9437
Mailing Address - Fax:
Practice Address - Street 1:16750 INDEX ST
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-3606
Practice Address - Country:US
Practice Address - Phone:818-425-9437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health