MEDICARE: VIBRANTCARE OUTPATIENT REHABILITATION WEST INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center	OTC-3770	AZ

General Provider Information

NPI Number	:	1699779223
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VIBRANTCARE OUTPATIENT REHABILITATION WEST INC

Provider Business Mailing Address
First Line	:	PO BOX 840301
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90084-0301
Country	:	US
Telephone Number	:	916-789-8115
Fax Number	:	916-773-1481

Provider Business Practice Location Address
First Line	:	6246 E PIMA ST
Second Line	:	SUITE 160
City	:	TUCSON
State	:	AZ
Zip	:	85712-3156
Country	:	US
Telephone Number	:	520-721-0319
Fax Number	:	520-733-5810

Authorized Official
Title or Position	:	CEO
Name	:	MR. DAVID SMITH
Credential	:
Telephone Number	:	916-782-1212

Provider Enumeration Date	:	06/10/2005
Last Update Date	:	11/20/2023

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