Healthcare Provider Details

I. General information

NPI: 1437960077
Provider Name (Legal Business Name): LA VIDA MEDICAL GROUP , INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2025
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3802 GUNN HWY
TAMPA FL
33618-8793
US

IV. Provider business mailing address

3802 GUNN HWY
TAMPA FL
33618-8793
US

V. Phone/Fax

Practice location:
  • Phone: 813-296-6266
  • Fax: 813-522-8929
Mailing address:
  • Phone: 813-296-6266
  • Fax: 813-522-8929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SANLLY PEREZ CEBALLOS
Title or Position: PRESIDENT
Credential: MD
Phone: 813-296-6266