Provider Demographics
NPI:1912300757
Name:VIDE, JORINDA
Entity Type:Individual
Prefix:
First Name:JORINDA
Middle Name:
Last Name:VIDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2351 37TH ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-1907
Mailing Address - Country:US
Mailing Address - Phone:630-335-1623
Mailing Address - Fax:
Practice Address - Street 1:2351 37TH ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-1907
Practice Address - Country:US
Practice Address - Phone:630-335-1623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-08
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008074133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered