Provider Demographics
NPI:1710753504
Name:VIDA MEDICAL, P.A. KA
Entity Type:Organization
Organization Name:VIDA MEDICAL, P.A. KA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR MANAGER, COMPLIANCE
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:ODONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-721-6214
Mailing Address - Street 1:100 MONTGOMERY ST STE 750
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94104-4302
Mailing Address - Country:US
Mailing Address - Phone:415-989-1017
Mailing Address - Fax:
Practice Address - Street 1:100 MONTGOMERY ST STE 750
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94104-4302
Practice Address - Country:US
Practice Address - Phone:415-989-1017
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-01
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center