Provider Demographics
NPI:1225433121
Name:VITALITY WOMEN'S PHYSICAL THERAPY AND WELLNESS, LLC
Entity Type:Organization
Organization Name:VITALITY WOMEN'S PHYSICAL THERAPY AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:SERGEANT
Authorized Official - Last Name:HUNGATE
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, WCS, MS
Authorized Official - Phone:331-215-4164
Mailing Address - Street 1:263 N YORK ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-2758
Mailing Address - Country:US
Mailing Address - Phone:331-215-4164
Mailing Address - Fax:331-223-9724
Practice Address - Street 1:263 N YORK ST
Practice Address - Street 2:SUITE 200
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-2758
Practice Address - Country:US
Practice Address - Phone:331-215-4164
Practice Address - Fax:331-223-9724
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224Y00000X
IL070013653225100000X
IL070013648225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No224Y00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersClinical Exercise PhysiologistGroup - Multi-Specialty