Provider Demographics
NPI:1063185684
Name:PRO VITA PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:PRO VITA PHYSICAL THERAPY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BULLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-902-7315
Mailing Address - Street 1:638 N FERDON BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-2170
Mailing Address - Country:US
Mailing Address - Phone:850-710-7163
Mailing Address - Fax:855-975-2471
Practice Address - Street 1:1987 HIGHWAY 87
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:FL
Practice Address - Zip Code:32566-1046
Practice Address - Country:US
Practice Address - Phone:850-710-7163
Practice Address - Fax:855-975-2471
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRO VITA PHYSICAL THERAPY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-07-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS0MOAOtherFLORIDA BLUE