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General NPI Number Information
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NPI Number | 1629795273
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Entity Type | Organization
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Legal Business Name | VITAL PERFORMANCE PHYSICAL THERAPY LLC
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Dates
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Enumeration Date | 10/25/2022
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Last Update Date | 10/25/2022
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Provider Practice Location Address
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Address Line | 9 MARY WAY
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City | HAINESPORT
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State | NJ
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Zip | 08036-2729
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Country | US
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Telephone | 609-676-5905
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Fax |
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Provider Business Mailing Address
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Address Line | 130 RANCOCAS RD
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City | MOUNT HOLLY
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State | NJ
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Zip | 08060-1320
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Country | US
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Telephone | 609-864-1709
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. MICHAEL SHADDOW
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Credential | DPT
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Telephone | 609-864-1709
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number |
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License Number State |
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