Provider Demographics
NPI:1992314744
Name:VIDAMOR MEDICAL
Entity type:Organization
Organization Name:VIDAMOR MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDRES
Authorized Official - Middle Name:
Authorized Official - Last Name:IBARRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-282-1544
Mailing Address - Street 1:107 REED RD
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-8605
Mailing Address - Country:US
Mailing Address - Phone:830-282-1544
Mailing Address - Fax:830-319-9192
Practice Address - Street 1:107 REED RD
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-8605
Practice Address - Country:US
Practice Address - Phone:210-393-2111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-28
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care