Basic Information
| Provider Information | |||||||||
| NPI: | 1477507432 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VIBRA SPECIALTY HOSPITAL OF DALLAS, LLC | ||||||||
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| OtherOrganizationName: | VIBRA SPECIALTY HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 E RIVER PARK PLACE E #460 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937201560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5598922500 | ||||||||
| FaxNumber: | 5598922442 | ||||||||
| Practice Location | |||||||||
| Address1: | 2700 WALKER WAY | ||||||||
| Address2: | |||||||||
| City: | DESOTO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751152088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146381500 | ||||||||
| FaxNumber: | 2146384545 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 07/02/2020 | ||||||||
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| AuthorizedOfficialLastName: | FEGAN | ||||||||
| AuthorizedOfficialFirstName: | CLINT | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY/TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 7175915700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 07/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282E00000X | 008391 | TX | Y | Hospitals | Long Term Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1979767-01 | 05 | TX | MEDICAID |