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General NPI Number Information
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NPI Number | 1003845942
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Entity Type | Organization
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Legal Business Name | VIDA VITAL LLC
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Dates
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Enumeration Date | 07/02/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1490 W 68TH ST 201
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City | HIALEAH
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State | FL
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Zip | 33014-4590
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Country | US
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Telephone | 786-256-9747
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Fax |
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Provider Business Mailing Address
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Address Line | 1490 W 68TH ST 201
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City | HIALEAH
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State | FL
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Zip | 33014-4590
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Country | US
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Telephone | 786-256-9747
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | YAILEN BENGOCHEA
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Credential |
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Telephone | 786-256-9747
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 173000000X
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Taxonomy Name | Legal Medicine
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License Number | HCC7020
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License Number State | FL
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