Provider Demographics
NPI:1376090290
Name:VIBRANT PHYSICAL THERAPY REHABILITATION PC
Entity Type:Organization
Organization Name:VIBRANT PHYSICAL THERAPY REHABILITATION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:IRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAMMAY
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:201-844-1992
Mailing Address - Street 1:321 AVENUE P FL 1
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-4135
Mailing Address - Country:US
Mailing Address - Phone:201-844-1992
Mailing Address - Fax:347-713-4525
Practice Address - Street 1:321 AVENUE P FL 1
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-4135
Practice Address - Country:US
Practice Address - Phone:201-844-1992
Practice Address - Fax:347-713-4525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY02204225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty