Provider Demographics
NPI:1598519357
Name:VVID LLC
Entity type:Organization
Organization Name:VVID LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPHINE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARTS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:707-567-1674
Mailing Address - Street 1:PO BOX 786
Mailing Address - Street 2:
Mailing Address - City:BETHEL ISLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94511-0786
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:191 SAND CREEK RD # CA230
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-2215
Practice Address - Country:US
Practice Address - Phone:925-663-8158
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-16
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Single Specialty