1619621000 NPI number — VIDA THERAPY GROUP, LLC

Table of content: (NPI 1619621000)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619621000 NPI number — VIDA THERAPY GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VIDA THERAPY GROUP, LLC
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:
1619621000
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
122 S GOLD AVE STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEMING
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88030-3755
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-283-0200
Provider Business Mailing Address Fax Number:
575-283-0238

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
122 S GOLD AVE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEMING
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88030-3755
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-283-0200
Provider Business Practice Location Address Fax Number:
575-283-0238
Provider Enumeration Date:
02/05/2022

Additional Information

Authorized Official

Authorized Official Last Name:
WESTENHOFER
Authorized Official First Name:
ADAM
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
575-283-0200

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 82271551 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com