Provider Demographics
NPI:1699034827
Name:MONTCLAIR VIDA HEALTH CLINIC PC
Entity Type:Organization
Organization Name:MONTCLAIR VIDA HEALTH CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GINGER
Authorized Official - Middle Name:L
Authorized Official - Last Name:LEON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:909-949-4400
Mailing Address - Street 1:5404 MORENO ST
Mailing Address - Street 2:SUITE N&P
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-1667
Mailing Address - Country:US
Mailing Address - Phone:909-949-4400
Mailing Address - Fax:909-949-4441
Practice Address - Street 1:5404 MORENO ST
Practice Address - Street 2:SUITE N&P
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763
Practice Address - Country:US
Practice Address - Phone:909-949-4400
Practice Address - Fax:909-949-4441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-08
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8311261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service