MEDICARE: VIDA VITAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	173000000X	Legal Medicine	HCC7020	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	HCC7020	OTHER	FL	HEALTH DEPT LICENSE

General Provider Information

NPI Number	:	1003845942
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VIDA VITAL LLC

Provider Business Mailing Address
First Line	:	1490 W 68TH ST
Second Line	:	201
City	:	HIALEAH
State	:	FL
Zip	:	33014-4590
Country	:	US
Telephone Number	:	786-256-9747
Fax Number	:

Provider Business Practice Location Address
First Line	:	1490 W 68TH ST
Second Line	:	201
City	:	HIALEAH
State	:	FL
Zip	:	33014-4590
Country	:	US
Telephone Number	:	786-256-9747
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	YAILEN BENGOCHEA
Credential	:
Telephone Number	:	786-256-9747

Provider Enumeration Date	:	07/02/2006
Last Update Date	:	08/22/2020

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Directions to “VIDA VITAL LLC ” Practice Location

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