Provider Demographics
NPI:1922714591
Name:VIDA ENTERA THERAPEUTIC SERVICES
Entity Type:Organization
Organization Name:VIDA ENTERA THERAPEUTIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:AGUILAR
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:575-421-0510
Mailing Address - Street 1:PO BOX 397
Mailing Address - Street 2:
Mailing Address - City:RIBERA
Mailing Address - State:NM
Mailing Address - Zip Code:87560-0397
Mailing Address - Country:US
Mailing Address - Phone:575-421-0510
Mailing Address - Fax:855-947-2816
Practice Address - Street 1:12 SAGEBRUSH WAY
Practice Address - Street 2:
Practice Address - City:RIBERA
Practice Address - State:NM
Practice Address - Zip Code:87560-8014
Practice Address - Country:US
Practice Address - Phone:575-421-0510
Practice Address - Fax:855-947-2816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-26
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty