Provider Demographics
NPI:1811991466
Name:VIBRANTCARE OUTPATIENT REHABILITATION WEST INC
Entity type:Organization
Organization Name:VIBRANTCARE OUTPATIENT REHABILITATION WEST INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-782-1212
Mailing Address - Street 1:PO BOX 840301
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90084-0301
Mailing Address - Country:US
Mailing Address - Phone:916-789-8115
Mailing Address - Fax:916-773-1481
Practice Address - Street 1:440 N CAMINO MERCADO STE 8
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-5750
Practice Address - Country:US
Practice Address - Phone:520-836-7996
Practice Address - Fax:520-836-5299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-10
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC-3769261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ03-6577Medicare ID - Type Unspecified