Provider Demographics
NPI:1063567832
Name:VIDA FAMILY MEDICINE, LLC
Entity type:Organization
Organization Name:VIDA FAMILY MEDICINE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TERI
Authorized Official - Middle Name:L
Authorized Official - Last Name:LITKE-FETSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-399-1400
Mailing Address - Street 1:PO BOX 883
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97308-0883
Mailing Address - Country:US
Mailing Address - Phone:503-399-1400
Mailing Address - Fax:503-399-1406
Practice Address - Street 1:374 OWENS ST SE STE 100
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4183
Practice Address - Country:US
Practice Address - Phone:503-399-1400
Practice Address - Fax:503-399-1406
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR132645Medicare ID - Type UnspecifiedPRACTICE MEDICARE #