Healthcare Provider Details

I. General information

NPI: 1003955725
Provider Name (Legal Business Name): STEPHEN A VIGHETTI PT, MTC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4020 GRANDE VISTA BLVD #114
ST AUGUSTINE FL
32084-1323
US

IV. Provider business mailing address

4020 GRANDE VISTA BLVD #114
ST AUGUSTINE FL
32084-1323
US

V. Phone/Fax

Practice location:
  • Phone: 904-315-3416
  • Fax:
Mailing address:
  • Phone: 904-315-3416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT21615
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: