Organization
PRO VITA PHYSICAL THERAPY LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CARLA BULLA (OWNER)
(850) 902-7315
Entity
Organization
Contact information
Practice address
638 N FERDON BLVD STE 1, CRESTVIEW, FL 32536-2170
(850) 331-3017
(855) 975-2575
Mailing address
638 N FERDON BLVD STE 1, CRESTVIEW, FL 32536-2170
(850) 331-3017
(855) 975-2575
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
—
—
225X00000X
Occupational Therapist
—
—
261QP2000X
Physical Therapy Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
103517900
—
FL
01
—
8JY2N
FLORIDA BLUE
FL
Enumeration date
08/19/2019
Last updated
08/29/2022
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