Provider Demographics
NPI:1487035093
Name:MI VIDA PRIMARY CARE LLC
Entity Type:Organization
Organization Name:MI VIDA PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:PENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:956-789-5515
Mailing Address - Street 1:3318 N 21ST ST
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78501-6062
Mailing Address - Country:US
Mailing Address - Phone:956-789-5515
Mailing Address - Fax:361-396-1283
Practice Address - Street 1:3318 N 21ST ST
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78501-6062
Practice Address - Country:US
Practice Address - Phone:956-789-5515
Practice Address - Fax:361-396-1283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-10
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP126924363LA2200X, 363LC1500X, 363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
No363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity HealthGroup - Single Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty