Provider Demographics
NPI:1578936787
Name:VIDADYNE HEALTHCARE LLC
Entity Type:Organization
Organization Name:VIDADYNE HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:JENNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-201-6167
Mailing Address - Street 1:14820 N CAVE CREEK RD
Mailing Address - Street 2:STE 2
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-4953
Mailing Address - Country:US
Mailing Address - Phone:480-646-3478
Mailing Address - Fax:480-712-4695
Practice Address - Street 1:14820 N CAVE CREEK RD
Practice Address - Street 2:STE 2
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-4953
Practice Address - Country:US
Practice Address - Phone:480-646-3478
Practice Address - Fax:480-712-4695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-10
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health