Healthcare Provider Details

I. General information

NPI: 1457109704
Provider Name (Legal Business Name): SEBASTIAN LUIZ VIGIL
Entity Type: Individual
Gender:
Sole Proprietor: N

Provider Other Name: RUKI VIGIL

II. Dates (important events)

Enumeration Date: 05/10/2024
Last Update Date: 05/10/2024
Certification Date: 05/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21600 OXNARD ST STE 200
WOODLAND HILLS CA
91367-4971
US

IV. Provider business mailing address

21600 OXNARD ST STE 200
WOODLAND HILLS CA
91367-4971
US

V. Phone/Fax

Practice location:
  • Phone: 877-206-1009
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: