Provider Demographics
NPI:1295106490
Name:VIDA LIFE ACUPUNCTURE MEDICAL CARE
Entity type:Organization
Organization Name:VIDA LIFE ACUPUNCTURE MEDICAL CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LICENSED ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:CHLOE
Authorized Official - Middle Name:
Authorized Official - Last Name:ELIAS
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:818-453-4074
Mailing Address - Street 1:12840 RIVERSIDE DR
Mailing Address - Street 2:401
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-3327
Mailing Address - Country:US
Mailing Address - Phone:818-453-4074
Mailing Address - Fax:
Practice Address - Street 1:12840 RIVERSIDE DR
Practice Address - Street 2:401
Practice Address - City:VALLEY VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91607-3327
Practice Address - Country:US
Practice Address - Phone:818-453-4074
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-13
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14314171100000X
CA16776171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty