Healthcare Provider Details

I. General information

NPI: 1780132662
Provider Name (Legal Business Name): VITAL REHABILITATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2016
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 PEORIA RD STE 202203
ORANGE PARK FL
32065-7685
US

IV. Provider business mailing address

2216 GREEN HERON CT
FLEMING ISLAND FL
32003-8600
US

V. Phone/Fax

Practice location:
  • Phone: 904-657-0089
  • Fax: 904-560-5283
Mailing address:
  • Phone: 904-434-5737
  • Fax: 904-512-3808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT28237
License Number StateFL

VIII. Authorized Official

Name: JENNIFER JUSTICE
Title or Position: OWNER/PHYSICAL THERAPIST
Credential: DPT
Phone: 904-434-5737