Provider Demographics
NPI:1255776498
Name:VIDA KELLER RISTON RN CNM PC
Entity type:Organization
Organization Name:VIDA KELLER RISTON RN CNM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:VIDA
Authorized Official - Middle Name:
Authorized Official - Last Name:RISTON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP, CNM
Authorized Official - Phone:409-838-4472
Mailing Address - Street 1:PO BOX 12667
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77726-2667
Mailing Address - Country:US
Mailing Address - Phone:409-838-4472
Mailing Address - Fax:409-838-0496
Practice Address - Street 1:2929 CALDER ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1845
Practice Address - Country:US
Practice Address - Phone:409-838-4472
Practice Address - Fax:409-838-0496
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-01
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX540793367A00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Multi-Specialty