Healthcare Provider Details

I. General information

NPI: 1073050043
Provider Name (Legal Business Name): CLINIC VIDA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2017
Last Update Date: 03/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73 S PALM AVE SUITE 223
SARASOTA FL
34236-5638
US

IV. Provider business mailing address

73 S PALM AVE SUITE 223
SARASOTA FL
34236-5638
US

V. Phone/Fax

Practice location:
  • Phone: 941-879-7388
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License NumberAP3476
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code175L00000X
TaxonomyHomeopath
License NumberAP3476
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAP3476
License Number StateFL

VIII. Authorized Official

Name: THERESA BARCUS
Title or Position: ACUPUNCTURE PHYSICIAN, DOCTOR OF OR
Credential: L.AP, DOM, BSPH, MOA
Phone: 941-879-7388