Provider Demographics
NPI:1083059539
Name:VIBRA HOSPITAL OF SPRINGFIELD LLC
Entity Type:Organization
Organization Name:VIBRA HOSPITAL OF SPRINGFIELD LLC
Other - Org Name:VIBRA HOSPITAL OF SPRINGFIELD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SEC/TREAS
Authorized Official - Prefix:MR
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:T
Authorized Official - Last Name:FEGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-591-5700
Mailing Address - Street 1:8081 ROYAL RIDGE PARKWAY
Mailing Address - Street 2:SUITE 130
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-2840
Mailing Address - Country:US
Mailing Address - Phone:469-713-5470
Mailing Address - Fax:469-713-0480
Practice Address - Street 1:701 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4931
Practice Address - Country:US
Practice Address - Phone:217-528-1217
Practice Address - Fax:217-528-1633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-09
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0005900282E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282E00000XHospitalsLong Term Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL142014Medicare Oscar/Certification