Provider Demographics
NPI:1548214794
Name:VIDA'S GALLERY
Entity Type:Organization
Organization Name:VIDA'S GALLERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHERVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAMTOUB
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:818-342-7017
Mailing Address - Street 1:5231 ZELZAH AVE
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-2121
Mailing Address - Country:US
Mailing Address - Phone:818-416-2919
Mailing Address - Fax:
Practice Address - Street 1:18345 VANOWEN ST
Practice Address - Street 2:SUITE 'H'
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-5439
Practice Address - Country:US
Practice Address - Phone:818-342-7017
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAEXAMPED O/P332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5564440001Medicare NSC