1699779223 NPI number — VIBRANTCARE OUTPATIENT REHABILITATION WEST INC

Table of content: (NPI 1699779223)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699779223 NPI number — VIBRANTCARE OUTPATIENT REHABILITATION WEST INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VIBRANTCARE OUTPATIENT REHABILITATION WEST INC
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:
6
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:
1699779223
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 840301
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90084-0301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-789-8115
Provider Business Mailing Address Fax Number:
916-773-1481

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6246 E PIMA ST
Provider Second Line Business Practice Location Address:
SUITE 160
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85712-3156
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-721-0319
Provider Business Practice Location Address Fax Number:
520-733-5810
Provider Enumeration Date:
06/10/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
916-782-1212

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  OTC-3770 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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