Provider Demographics
NPI:1770058562
Name:VITALITY SPORT AND REHAB LLC
Entity type:Organization
Organization Name:VITALITY SPORT AND REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TAMEKA
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:931-444-3677
Mailing Address - Street 1:1477 TINY TOWN RD # 323
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-7202
Mailing Address - Country:US
Mailing Address - Phone:931-444-3677
Mailing Address - Fax:931-444-5581
Practice Address - Street 1:1477 TINY TOWN RD # 323
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37042-7202
Practice Address - Country:US
Practice Address - Phone:931-444-3677
Practice Address - Fax:931-444-5581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-08
Last Update Date:2018-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty