Healthcare Provider Details

I. General information

NPI: 1255775771
Provider Name (Legal Business Name): LA VIDA ADULT SOCIAL CARE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2013
Last Update Date: 04/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5030 BROADWAY SUITE # 804
NEW YORK NY
10034-1609
US

IV. Provider business mailing address

5030 BROADWAY SUITE #804
NEW YORK NY
10034-1609
US

V. Phone/Fax

Practice location:
  • Phone: 917-688-1543
  • Fax: 917-688-1542
Mailing address:
  • Phone: 917-688-1543
  • Fax: 917-688-1542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. VLADISLAV M. TOLCHEV
Title or Position: MEMBER-MANAGER
Credential:
Phone: 917-688-1543