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General NPI Number Information
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NPI Number | 1518365741
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Entity Type | Organization
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Legal Business Name | MI VIDA PRIMARY CARE LLC
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Dates
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Enumeration Date | 12/22/2014
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Last Update Date | 12/22/2014
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Provider Practice Location Address
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Address Line | 3318 N 21ST ST
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City | MCALLEN
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State | TX
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Zip | 78501-6062
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Country | US
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Telephone | 956-789-5515
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Fax | 361-396-1283
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Provider Business Mailing Address
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Address Line | 3318 N 21ST ST
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City | MCALLEN
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State | TX
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Zip | 78501-6062
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Country | US
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Telephone | 956-789-5515
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Fax | 361-396-1283
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | JOHN PENA
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Credential |
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Telephone | 956-624-9312
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | AP126924
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License Number State | TX
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