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General NPI Number Information
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NPI Number | 1336008036
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Entity Type | Organization
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Legal Business Name | VIDALTIA CORP.
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Dates
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Enumeration Date | 01/19/2026
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Last Update Date | 01/19/2026
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Provider Practice Location Address
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Address Line | 6456 NW 5TH WAY
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City | FORT LAUDERDALE
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State | FL
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Zip | 33309-6112
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Country | US
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Telephone | 202-802-0082
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Fax |
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Provider Business Mailing Address
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Address Line | 6456 NW 5TH WAY
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City | FORT LAUDERDALE
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State | FL
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Zip | 33309-6112
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Country | US
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Telephone | 202-802-0082
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. EZECHIEL FENELON
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Credential |
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Telephone | 202-802-0082
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QF0400X
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Taxonomy Name | Federally Qualified Health Center (FQHC)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QI0500X
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Taxonomy Name | Infusion Therapy Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QP0904X
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Taxonomy Name | Federal Public Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 261QP0905X
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Taxonomy Name | State or Local Public Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 261QP3300X
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Taxonomy Name | Pain Clinic/Center
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License Number |
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License Number State |
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Taxonomy #8
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Taxonomy Code | 261QV0200X
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Taxonomy Name | VA Clinic/Center
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License Number |
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License Number State |
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Taxonomy #9
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Taxonomy Code | 261QX0100X
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Taxonomy Name | Occupational Medicine Clinic/Center
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License Number |
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License Number State |
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Taxonomy #10
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Taxonomy Code | 281P00000X
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Taxonomy Name | Chronic Disease Hospital
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License Number |
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License Number State |
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Taxonomy #11
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number |
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License Number State |
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Taxonomy #12
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number |
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License Number State |
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Taxonomy #13
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number |
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License Number State |
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Taxonomy #14
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number |
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License Number State |
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Taxonomy #15
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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