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General NPI Number Information
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NPI Number | 1841944535
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Entity Type | Organization
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Legal Business Name | PRO VITA PHYSICAL THERAPY LLC
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Dates
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Enumeration Date | 02/10/2022
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Last Update Date | 02/13/2026
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Provider Practice Location Address
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Address Line | 411 RACETRACK RD NE
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-2503
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Country | US
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Telephone | 850-331-3017
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Fax | 855-978-1838
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Provider Business Mailing Address
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Address Line | 638 N FERDON BLVD STE 1
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City | CRESTVIEW
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State | FL
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Zip | 32536-2170
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Country | US
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Telephone | 850-331-3017
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Fax | 855-975-2575
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Authorized Official
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Title or Position | OWNER
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Name | CARLA J BULLA
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Credential |
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Telephone | 850-331-3017
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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