Healthcare Provider Details

I. General information

NPI: 1861937179
Provider Name (Legal Business Name): ISLAND MEDICAL VIBRA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2016
Last Update Date: 12/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8049 SOUTH AVE
BOARDMAN OH
44512-6154
US

IV. Provider business mailing address

PO BOX 774798
CLEVELAND OH
44194-4798
US

V. Phone/Fax

Practice location:
  • Phone: 330-726-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: DANIEL R FERRARA
Title or Position: PRESIDENT
Credential: DO
Phone: 631-514-7600