Provider Demographics
NPI:1740514629
Name:VITALITY SPINE & SPORTS PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:VITALITY SPINE & SPORTS PHYSICAL THERAPY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:HINKLE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:520-867-8064
Mailing Address - Street 1:15920 S RANCHO SAHUARITA BLVD STE 160
Mailing Address - Street 2:
Mailing Address - City:SAHUARITA
Mailing Address - State:AZ
Mailing Address - Zip Code:85629-8014
Mailing Address - Country:US
Mailing Address - Phone:520-867-8064
Mailing Address - Fax:520-867-8063
Practice Address - Street 1:15920 S RANCHO SAHUARITA BLVD
Practice Address - Street 2:SUITE 160
Practice Address - City:SAHUARITA
Practice Address - State:AZ
Practice Address - Zip Code:85629-8012
Practice Address - Country:US
Practice Address - Phone:520-867-8064
Practice Address - Fax:520-867-8063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-25
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4064225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty