Provider Demographics
NPI:1265479406
Name:VITAL CARE REHABILITATION, LLC
Entity Type:Organization
Organization Name:VITAL CARE REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCWHORTER
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:623-544-0300
Mailing Address - Street 1:14545 W GRAND AVE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-7278
Mailing Address - Country:US
Mailing Address - Phone:623-544-0300
Mailing Address - Fax:623-544-0239
Practice Address - Street 1:14545 W GRAND AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-7278
Practice Address - Country:US
Practice Address - Phone:623-544-0300
Practice Address - Fax:623-544-0239
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
AZ261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ034509Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER