Healthcare Provider Details

I. General information

NPI: 1619823036
Provider Name (Legal Business Name): VIVID MED SPA, PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2026
Last Update Date: 03/09/2026
Certification Date: 03/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 E GOBBI ST
UKIAH CA
95482-4918
US

IV. Provider business mailing address

166 E GOBBI ST
UKIAH CA
95482-4918
US

V. Phone/Fax

Practice location:
  • Phone: 707-414-0419
  • Fax:
Mailing address:
  • Phone: 707-414-0419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. RIA PRAKASH JIVAN
Title or Position: CEO
Credential: RN
Phone: 903-363-5914