Provider Demographics
NPI:1053196568
Name:PRO VITA PHYSICAL THERAPY - FLORALA
Entity type:Organization
Organization Name:PRO VITA PHYSICAL THERAPY - FLORALA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
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:850-331-3017
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:850-331-3017
Mailing Address - Fax:855-275-2575
Practice Address - Street 1:804 ELM ST
Practice Address - Street 2:
Practice Address - City:FLORALA
Practice Address - State:AL
Practice Address - Zip Code:36442-3560
Practice Address - Country:US
Practice Address - Phone:850-331-3017
Practice Address - Fax:855-275-6191
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRO VITA PHYSICAL THERAPY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-08-31
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy