=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811991466
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIBRANTCARE OUTPATIENT REHABILITATION WEST INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2005
-----------------------------------------------------
Last Update Date | 11/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 440 N CAMINO MERCADO STE 8
-----------------------------------------------------
City | CASA GRANDE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85122-5750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-836-7996
-----------------------------------------------------
Fax | 520-836-5299
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 840301
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90084-0301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-789-8115
-----------------------------------------------------
Fax | 916-773-1481
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. DAVID SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 916-782-1212
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | OTC-3769
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------