Provider Demographics
NPI:1972817534
Name:VIDA NUEVA #1 CORP.
Entity Type:Organization
Organization Name:VIDA NUEVA #1 CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-312-4259
Mailing Address - Street 1:745 N.W. 102 ST.
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33150
Mailing Address - Country:US
Mailing Address - Phone:305-758-1629
Mailing Address - Fax:305-758-1958
Practice Address - Street 1:745 N.W. 102 ST.
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33150
Practice Address - Country:US
Practice Address - Phone:305-758-1629
Practice Address - Fax:305-758-1958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-05
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL10840310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001988309Medicaid