Provider Demographics
NPI:1528203049
Name:VIBRA HOSPITAL OF MAHONING VALLEY LLC
Entity Type:Organization
Organization Name:VIBRA HOSPITAL OF MAHONING VALLEY LLC
Other - Org Name:VIBRA HOSPITAL OF MAHONING VALLEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SEC/TREAS
Authorized Official - Prefix:MR
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:T
Authorized Official - Last Name:FEGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-591-5700
Mailing Address - Street 1:5 EAST RIVER PARK PLACE E #460
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-1560
Mailing Address - Country:US
Mailing Address - Phone:559-892-2500
Mailing Address - Fax:559-892-2442
Practice Address - Street 1:8049 SOUTH AVE
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-6154
Practice Address - Country:US
Practice Address - Phone:330-726-5021
Practice Address - Fax:330-726-5053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-12
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1428282E00000X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282E00000XHospitalsLong Term Care Hospital
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3140729Medicaid
PA1032312470001Medicaid
PA1032312470001Medicaid