Healthcare Provider Details

I. General information

NPI: 1023574498
Provider Name (Legal Business Name): SARA ANDREA VIDES CADC III
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2019
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12580 LAKELAND RD
SANTA FE SPRINGS CA
90670-3940
US

IV. Provider business mailing address

12580 LAKELAND RD
SANTA FE SPRINGS CA
90670-3940
US

V. Phone/Fax

Practice location:
  • Phone: 562-906-2685
  • Fax: 562-777-7510
Mailing address:
  • Phone: 562-906-2685
  • Fax: 562-777-7510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number22337
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: