Provider Demographics
NPI:1790332351
Name:PRO VITA PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:PRO VITA PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:BULLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-902-7315
Mailing Address - Street 1:638 N FERDON BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-2170
Mailing Address - Country:US
Mailing Address - Phone:850-331-3017
Mailing Address - Fax:855-975-2575
Practice Address - Street 1:638 N FERDON BLVD STE 1
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-2170
Practice Address - Country:US
Practice Address - Phone:850-331-3017
Practice Address - Fax:855-975-2575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-19
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8JY2NOtherFLORIDA BLUE
FL103517900Medicaid