Healthcare Provider Details

I. General information

NPI: 1518395631
Provider Name (Legal Business Name): VIDA NUEVA ADULT DAY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2013
Last Update Date: 01/28/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 W ZAVALA ST
CRYSTAL CITY TX
78839-3241
US

IV. Provider business mailing address

409 W ZAVALA ST
CRYSTAL CITY TX
78839-3241
US

V. Phone/Fax

Practice location:
  • Phone: 830-854-2001
  • Fax: 830-854-2150
Mailing address:
  • Phone: 830-854-2001
  • Fax: 830-854-2150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number139178
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number StateTX

VIII. Authorized Official

Name: ESPERANZA RUIZ
Title or Position: FACILITY MANAGER
Credential:
Phone: 830-694-2445