Provider Demographics
NPI:1639576093
Name:VITAL REHABILITATION LLC.
Entity Type:Organization
Organization Name:VITAL REHABILITATION LLC.
Other - Org Name:VITAL SPORTS AND WELLNESS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER, CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:AMANDA
Authorized Official - Last Name:JUSTICE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT, SCS
Authorized Official - Phone:904-657-0089
Mailing Address - Street 1:2216 GREEN HERON CT
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-8600
Mailing Address - Country:US
Mailing Address - Phone:904-434-5737
Mailing Address - Fax:
Practice Address - Street 1:3600 PEORIA RD STE 203
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-7686
Practice Address - Country:US
Practice Address - Phone:904-657-0089
Practice Address - Fax:904-560-5283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-01
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA38374OtherMASSAGE THERAPY