Provider Demographics
NPI:1437960077
Name:LA VIDA MEDICAL GROUP , INC
Entity type:Organization
Organization Name:LA VIDA MEDICAL GROUP , INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SANLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ CEBALLOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-296-6266
Mailing Address - Street 1:3802 GUNN HWY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618-8793
Mailing Address - Country:US
Mailing Address - Phone:813-296-6266
Mailing Address - Fax:813-522-8929
Practice Address - Street 1:3802 GUNN HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-8793
Practice Address - Country:US
Practice Address - Phone:813-296-6266
Practice Address - Fax:813-522-8929
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LA VIDA MEDICAL GROUP INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-01-14
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty