Healthcare Provider Details

I. General information

NPI: 1700027471
Provider Name (Legal Business Name): LA VIDA MEDICAL CV INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2009
Last Update Date: 03/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4161 REDONDO BEACH BLVD # 300
LAWNDALE CA
90260-3306
US

IV. Provider business mailing address

4161 REDONDO BEACH BLVD # 300
LAWNDALE CA
90260-3306
US

V. Phone/Fax

Practice location:
  • Phone: 310-214-8677
  • Fax: 310-921-1716
Mailing address:
  • Phone: 310-214-8677
  • Fax: 310-921-1716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberC3129855
License Number StateCA

VIII. Authorized Official

Name: CHRISTOPHER CHIDI
Title or Position: PRESIDENT
Credential:
Phone: 310-214-8677