Provider Demographics
NPI:1235911611
Name:VIDA RECOVERY LLC
Entity type:Organization
Organization Name:VIDA RECOVERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHILOH
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCLELLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-227-2291
Mailing Address - Street 1:812 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:JOURDANTON
Mailing Address - State:TX
Mailing Address - Zip Code:78026-2940
Mailing Address - Country:US
Mailing Address - Phone:830-399-5010
Mailing Address - Fax:
Practice Address - Street 1:10127 MOROCCO ST STE 196
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-3943
Practice Address - Country:US
Practice Address - Phone:830-216-6563
Practice Address - Fax:330-595-4025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-19
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty