Healthcare Provider Details

I. General information

NPI: 1255360152
Provider Name (Legal Business Name): VIDA SANA MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 N. SEQUOIA AVE. SUITE B
LINDSAY CA
93247
US

IV. Provider business mailing address

755 N. SEQUOIA AVE. SUITE B
LINDSAY CA
93247
US

V. Phone/Fax

Practice location:
  • Phone: 559-562-9399
  • Fax: 559-562-9379
Mailing address:
  • Phone: 559-562-9399
  • Fax: 559-562-9379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG48642
License Number StateCA

VIII. Authorized Official

Name: MR. BENJAMIN CORDOVA
Title or Position: ADMINISTRATOR
Credential:
Phone: 559-562-9399