MEDICARE: VITA PHYSICAL THERAPY AND WELLNESS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1124617501
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITA PHYSICAL THERAPY AND WELLNESS LLC

Provider Business Mailing Address
First Line	:	2844 ANNELISE WAY
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-7659
Country	:	US
Telephone Number	:	860-416-8754
Fax Number	:

Provider Business Practice Location Address
First Line	:	2550 STOVER ST UNIT F
Second Line	:
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-4643
Country	:	US
Telephone Number	:	860-416-8754
Fax Number	:

Authorized Official
Title or Position	:	PHYSICAL THERAPIST
Name	:	MICHELLE BARDINO FARIS
Credential	:	PT, DPT, CLT-LANA
Telephone Number	:	860-416-8754

Provider Enumeration Date	:	01/11/2021
Last Update Date	:	01/11/2021

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