Provider Demographics
NPI:1952634602
Name:PROJECT VIDA
Entity Type:Organization
Organization Name:PROJECT VIDA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RODRIGO
Authorized Official - Middle Name:
Authorized Official - Last Name:CEBALLOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-589-5519
Mailing Address - Street 1:3612 PERA AVE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-2412
Mailing Address - Country:US
Mailing Address - Phone:915-533-7057
Mailing Address - Fax:915-533-7158
Practice Address - Street 1:3612 PERA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2412
Practice Address - Country:US
Practice Address - Phone:915-533-7057
Practice Address - Fax:915-533-7158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-14
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX678490261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health