Provider Demographics
NPI:1982377065
Name:LA VIDA MEDICAL GROUP , INC
Entity Type:Organization
Organization Name:LA VIDA MEDICAL GROUP , INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SANLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ CEBALLOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-296-6266
Mailing Address - Street 1:120 STATE ST E STE 101
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-3647
Mailing Address - Country:US
Mailing Address - Phone:813-296-6266
Mailing Address - Fax:813-522-8929
Practice Address - Street 1:120 STATE ST E STE 101
Practice Address - Street 2:
Practice Address - City:OLDSMAR
Practice Address - State:FL
Practice Address - Zip Code:34677-3647
Practice Address - Country:US
Practice Address - Phone:813-296-6266
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-26
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty