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NPI Code Detail

MEDICARE: VIDA CLINIC PLLC

MEDICARE: VIDA CLINIC PLLC
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
1251S00000XCommunity/Behavioral Health Agency34166TX
2103TC0700XClinical Psychologist34166TX

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1912389081
Entity Type Code : Organization
Provider Name (Legal Business Name) : VIDA CLINIC PLLC
Provider Business Mailing Address
First Line : 1221 W BEN WHITE BLVD STE 210A
Second Line :
City : AUSTIN
State : TX
Zip : 78704-7182
Country : US
Telephone Number : 512-960-4533
Fax Number : 512-887-3970
Provider Business Practice Location Address
First Line : 1221 W BEN WHITE BLVD STE 210A
Second Line :
City : AUSTIN
State : TX
Zip : 78704-7182
Country : US
Telephone Number : 512-960-4533
Fax Number : 512-887-3970
Authorized Official
Title or Position : BUSINESS MANAGER
Name : ALAIN STORDAHL
Credential :
Telephone Number : 512-537-7976
Provider Enumeration Date : 06/24/2015
Last Update Date : 08/16/2021

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Directions to “VIDA CLINIC PLLC ” Practice Location

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