1295513562 NPI number — VITAL FORTITUDE REHAB AND PERFORMANCE

Table of content: (NPI 1295513562)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295513562 NPI number — VITAL FORTITUDE REHAB AND PERFORMANCE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VITAL FORTITUDE REHAB AND PERFORMANCE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295513562
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2108 N ST # N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95816-5712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-503-5438
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5030 CAMINO DE LA SIESTA
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92108-3116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-365-5463
Provider Business Practice Location Address Fax Number:
877-503-7863
Provider Enumeration Date:
09/18/2023

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
EVAN
Authorized Official Title or Position:
PHYSICAL THERAPIST, OWNER, FOUNDER
Authorized Official Telephone Number:
909-503-5438

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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