Provider Demographics
NPI:1336143981
Name:VIBRANTCARE OUTPATIENT REHABILITATION OF CALIFORNIA INC
Entity Type:Organization
Organization Name:VIBRANTCARE OUTPATIENT REHABILITATION OF CALIFORNIA INC
Other - Org Name:VIBRANTCARE OUTPATIENT REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-782-1212
Mailing Address - Street 1:2270 DOUGLAS BLVD
Mailing Address - Street 2:STE 112
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3869
Mailing Address - Country:US
Mailing Address - Phone:916-782-1212
Mailing Address - Fax:916-773-1481
Practice Address - Street 1:1357 W SHAW AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3618
Practice Address - Country:US
Practice Address - Phone:559-221-7390
Practice Address - Fax:559-221-1897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-10
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
05-6829Medicare ID - Type Unspecified