Provider Demographics
NPI:1639172133
Name:VIBRA HOSPITAL OF SAN DIEGO, LLC
Entity Type:Organization
Organization Name:VIBRA HOSPITAL OF SAN DIEGO, LLC
Other - Org Name:
Other - Org Type:
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 1:555 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2289
Practice Address - Country:US
Practice Address - Phone:619-260-8300
Practice Address - Fax:619-260-1268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-27
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA090000404282E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282E00000XHospitalsLong Term Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABR442AMedicare PIN
CA052044Medicare Oscar/Certification
CA1639172133Medicaid