=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073124509
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDELA VIDA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2020
-----------------------------------------------------
Last Update Date | 08/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6020 E BROWN RD STE 104
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85205-4812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-428-0700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6020 E BROWN RD STE 104
-----------------------------------------------------
City | MESA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85205-4812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-428-0700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TIMOTHY DEAN BINGHAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 480-331-0046
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP3300X
-----------------------------------------------------
Taxonomy Name | Pain Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------