Provider Demographics
NPI:1912389081
Name:VIDA CLINIC PLLC
Entity Type:Organization
Organization Name:VIDA CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALAIN
Authorized Official - Middle Name:
Authorized Official - Last Name:STORDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-537-7976
Mailing Address - Street 1:1221 W BEN WHITE BLVD STE 210A
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-7182
Mailing Address - Country:US
Mailing Address - Phone:512-960-4533
Mailing Address - Fax:512-887-3970
Practice Address - Street 1:1221 W BEN WHITE BLVD STE 210A
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-7182
Practice Address - Country:US
Practice Address - Phone:512-960-4533
Practice Address - Fax:512-887-3970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-24
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34166103TC0700X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3572935-01Medicaid