Healthcare Provider Details

I. General information

NPI: 1003845942
Provider Name (Legal Business Name): VIDA VITAL LLC
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

1490 W 68TH ST 201
HIALEAH FL
33014-4590
US

IV. Provider business mailing address

1490 W 68TH ST 201
HIALEAH FL
33014-4590
US

V. Phone/Fax

Practice location:
  • Phone: 786-256-9747
  • Fax:
Mailing address:
  • Phone: 786-256-9747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberHCC7020
License Number StateFL

VIII. Authorized Official

Name: YAILEN BENGOCHEA
Title or Position: PRESIDENT
Credential:
Phone: 786-256-9747