Provider Demographics
NPI:1588006266
Name:VIDACUPUNCTURE,LLC
Entity type:Organization
Organization Name:VIDACUPUNCTURE,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESISDENT
Authorized Official - Prefix:
Authorized Official - First Name:SILVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DE WYNNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-562-0850
Mailing Address - Street 1:5246 SW 8TH ST
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33134-2375
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17901 SW 296TH ST
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030-3138
Practice Address - Country:US
Practice Address - Phone:305-562-0850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP 3231261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center