=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982212171
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VITALITY REHABILITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2020
-----------------------------------------------------
Last Update Date | 07/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 450 KNIGHTS RUN AVE
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33602-6300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 403-389-4936
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7982
-----------------------------------------------------
City | SEMINOLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33775-7982
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-906-7221
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | JULIE WOLSTEIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 403-389-4936
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------