Healthcare Provider Details

I. General information

NPI: 1871887299
Provider Name (Legal Business Name): VIDA HEALTH CARE P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2011
Last Update Date: 06/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 W. LA HABRA BLVD.
LA HABRA CA
90631
US

IV. Provider business mailing address

202 W. LA HABRA BLVD.
LA HABRA CA
90631-5404
US

V. Phone/Fax

Practice location:
  • Phone: 562-694-0600
  • Fax: 562-694-0611
Mailing address:
  • Phone: 562-694-0600
  • Fax: 562-694-0611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A8311
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA17187
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA17142
License Number StateCA

VIII. Authorized Official

Name: GINGER LEON
Title or Position: MEDICAL DIRECTOR
Credential: D.O.
Phone: 562-694-0600