Healthcare Provider Details

I. General information

NPI: 1831300813
Provider Name (Legal Business Name): LA VIDA MEDICAL & IPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4161 REDONDO BEACH BLVD SUITE 201
LAWNDALE CA
90260-3306
US

IV. Provider business mailing address

4161 REDONDO BEACH BLVD SUITE 201
LAWNDALE CA
90260-3306
US

V. Phone/Fax

Practice location:
  • Phone: 310-214-8677
  • Fax: 310-370-7299
Mailing address:
  • Phone: 310-214-8677
  • Fax: 310-370-7299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number01443
License Number StateCA

VIII. Authorized Official

Name: MR. CHRISTOPHER C CHIDI
Title or Position: PRESIDENT
Credential: CEO
Phone: 310-214-8677