Provider Demographics
NPI:1215400056
Name:VICHER-VESAGAS, VIBETH JUDE (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:
First Name:VIBETH
Middle Name:JUDE
Last Name:VICHER-VESAGAS
Suffix:
Gender:F
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 S BRIDGESTONE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-7926
Mailing Address - Country:US
Mailing Address - Phone:904-535-7775
Mailing Address - Fax:
Practice Address - Street 1:813 S BRIDGESTONE AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-7926
Practice Address - Country:US
Practice Address - Phone:904-535-7775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8254225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist