Provider Demographics
NPI:1184086209
Name:VIDA FAMILY MEDICINE
Entity type:Organization
Organization Name:VIDA FAMILY MEDICINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TERI
Authorized Official - Middle Name:
Authorized Official - Last Name:LITKE
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
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:2016-03-28
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR07-12-12101YA0400X
ORL6901104100000X
ORT0986106H00000X
ORT0889106H00000X
OR201402104-NP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR132645Medicare UPIN