1023163227 NPI number — LA VIDA MULTI-SPECIALTY MEDICAL GROUP

Table of content: (NPI 1023163227)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023163227 NPI number — LA VIDA MULTI-SPECIALTY MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LA VIDA MULTI-SPECIALTY MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023163227
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
DEPARTMENT NO 2834
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELELS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90084-1236
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-214-8677
Provider Business Mailing Address Fax Number:
310-921-1718

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 S GRAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90015-3048
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
213-765-7500
Provider Business Practice Location Address Fax Number:
213-765-7390
Provider Enumeration Date:
01/25/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CHIDI
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
310-214-8677

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GR0088190 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".