Provider Demographics
NPI:1245549443
Name:VIDA FAMILY PRACTICE PC
Entity type:Organization
Organization Name:VIDA FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VIGEN
Authorized Official - Middle Name:VICK
Authorized Official - Last Name:ABOVIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-588-8178
Mailing Address - Street 1:PO BOX 5869
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91221-5869
Mailing Address - Country:US
Mailing Address - Phone:818-588-8178
Mailing Address - Fax:
Practice Address - Street 1:435 ARDEN AVE
Practice Address - Street 2:SUITE # 330
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-4016
Practice Address - Country:US
Practice Address - Phone:818-548-8001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-05
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA106757261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care