Provider Demographics
NPI:1629795273
Name:VITAL PERFORMANCE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:VITAL PERFORMANCE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHADDOW
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:609-864-1709
Mailing Address - Street 1:130 RANCOCAS RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOLLY
Mailing Address - State:NJ
Mailing Address - Zip Code:08060-1320
Mailing Address - Country:US
Mailing Address - Phone:609-864-1709
Mailing Address - Fax:
Practice Address - Street 1:9 MARY WAY
Practice Address - Street 2:
Practice Address - City:HAINESPORT
Practice Address - State:NJ
Practice Address - Zip Code:08036-2729
Practice Address - Country:US
Practice Address - Phone:609-676-5905
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy