Healthcare Provider Details

I. General information

NPI: 1396615290
Provider Name (Legal Business Name): LISA MARIE VIGIL RADT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2025
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14340 ELSWORTH ST STE 108
MORENO VALLEY CA
92553-9020
US

IV. Provider business mailing address

25898 PUMALO ST
SAN BERNARDINO CA
92404-3470
US

V. Phone/Fax

Practice location:
  • Phone: 951-419-7738
  • Fax:
Mailing address:
  • Phone: 909-844-7268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15049-RAC
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: