Provider Demographics
NPI:1740041748
Name:OPTVIDA, LLC
Entity type:Organization
Organization Name:OPTVIDA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:435-553-5915
Mailing Address - Street 1:98 E 500 S
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9801
Mailing Address - Country:US
Mailing Address - Phone:435-553-5915
Mailing Address - Fax:
Practice Address - Street 1:1034 RSI DR UNIT 120
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-2203
Practice Address - Country:US
Practice Address - Phone:435-704-9342
Practice Address - Fax:435-355-3874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty