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General NPI Number Information
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NPI Number | 1609571926
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Entity Type | Organization
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Legal Business Name | VIDA HEALTH SPA LLC
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Dates
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Enumeration Date | 04/04/2023
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Last Update Date | 04/04/2023
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Provider Practice Location Address
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Address Line | 215 E LAKE ST STE A
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City | BLOOMINGDALE
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State | IL
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Zip | 60108-1163
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Country | US
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Telephone | 773-996-3977
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Fax |
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Provider Business Mailing Address
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Address Line | 215 E LAKE ST STE A
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City | BLOOMINGDALE
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State | IL
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Zip | 60108-1163
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Country | US
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Telephone | 773-996-3977
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MARC CALABRIA
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Credential |
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Telephone | 708-369-6272
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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