Healthcare Provider Details

I. General information

NPI: 1639576093
Provider Name (Legal Business Name): VITAL REHABILITATION LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2014
Last Update Date: 01/31/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 PEORIA RD STE 203
ORANGE PARK FL
32065-7686
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:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER AMANDA JUSTICE
Title or Position: OWNER, CLINICIAN
Credential: DPT, SCS
Phone: 904-657-0089