Provider Demographics
NPI:1760129753
Name:VENGEANCE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:VENGEANCE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:ACOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:786-399-5515
Mailing Address - Street 1:331 85TH ST APT 24
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33141-4803
Mailing Address - Country:US
Mailing Address - Phone:786-399-5515
Mailing Address - Fax:
Practice Address - Street 1:331 85TH ST APT 24
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33141-4803
Practice Address - Country:US
Practice Address - Phone:786-399-5515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-19
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy