Healthcare Provider Details

I. General information

NPI: 1619621000
Provider Name (Legal Business Name): VIDA THERAPY GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2022
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 S GOLD AVE STE A
DEMING NM
88030-3755
US

IV. Provider business mailing address

122 S GOLD AVE STE A
DEMING NM
88030-3755
US

V. Phone/Fax

Practice location:
  • Phone: 575-283-0200
  • Fax: 575-283-0238
Mailing address:
  • Phone: 575-283-0200
  • Fax: 575-283-0238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. ADAM WESTENHOFER
Title or Position: OWNER
Credential: OTR/L, CHT
Phone: 575-283-0200