Provider Demographics
NPI:1245945807
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:MRS
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BULLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-331-3017
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:855-275-2575
Practice Address - Street 1:5941 BERRYHILL RD STE I
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-4043
Practice Address - Country:US
Practice Address - Phone:850-331-3017
Practice Address - Fax:855-595-2306
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRO VITA PHYSICAL THERAPY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty