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General NPI Number Information
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NPI Number | 1780560870
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Entity Type | Organization
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Legal Business Name | VIDA REVIVAL MEDICAL CORPORATION
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Dates
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Enumeration Date | 08/13/2025
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Last Update Date | 08/13/2025
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Provider Practice Location Address
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Address Line | 3180 WILLOW LN STE 114
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City | THOUSAND OAKS
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State | CA
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Zip | 91361-4984
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Country | US
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Telephone | 818-232-8432
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Fax | 818-232-8433
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Provider Business Mailing Address
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Address Line | 3180 WILLOW LN STE 114
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City | THOUSAND OAKS
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State | CA
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Zip | 91361-4984
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Country | US
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Telephone | 818-232-8432
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Fax | 818-232-8433
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Authorized Official
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Title or Position | MD/ CEO
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Name | DR. DIANA ALAVI
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Credential | MD/ CEO
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Telephone | 818-232-8452
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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 |
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License Number State |
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