Provider Demographics
NPI:1174867154
Name:VITAL PHYSICAL THERAPY INC.
Entity Type:Organization
Organization Name:VITAL PHYSICAL THERAPY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KOMAL
Authorized Official - Middle Name:
Authorized Official - Last Name:DEOKULE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-255-7976
Mailing Address - Street 1:PO BOX 910883
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92191-0883
Mailing Address - Country:US
Mailing Address - Phone:858-255-7976
Mailing Address - Fax:858-255-7969
Practice Address - Street 1:5820 OBERLIN DR STE 111
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3743
Practice Address - Country:US
Practice Address - Phone:858-255-7976
Practice Address - Fax:858-255-7969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA359862251C2600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251C2600XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistCardiopulmonaryGroup - Single Specialty