Provider Demographics
NPI:1720851413
Name:VIDA HEALTH WELLNESS, PLLC
Entity type:Organization
Organization Name:VIDA HEALTH WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAHENA
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:773-413-7264
Mailing Address - Street 1:5747 W FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-2353
Mailing Address - Country:US
Mailing Address - Phone:773-413-7264
Mailing Address - Fax:
Practice Address - Street 1:5747 W FULLERTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60639-2353
Practice Address - Country:US
Practice Address - Phone:773-413-7264
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-03
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty