Healthcare Provider Details

I. General information

NPI: 1962876557
Provider Name (Legal Business Name): VIDA THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2015
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9847 SW 184TH ST
PALMETTO BAY FL
33157-6934
US

IV. Provider business mailing address

11285 SW 211TH ST STE 207
CUTLER BAY FL
33189-2211
US

V. Phone/Fax

Practice location:
  • Phone: 786-227-6177
  • Fax: 786-842-3608
Mailing address:
  • Phone: 786-227-6177
  • Fax: 786-842-3608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AYREMIS RODRIGUEZ
Title or Position: PRESIDENT
Credential: MA
Phone: 786-227-6177