Healthcare Provider Details

I. General information

NPI: 1831167089
Provider Name (Legal Business Name): LARA ELIZABETH VIGGIANO MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CREEK CROSSING BLVD SUITE 107
HAINESPORT NJ
08036-2765
US

IV. Provider business mailing address

100 CREEK CROSSING BLVD SUITE 107
HAINESPORT NJ
08036-2765
US

V. Phone/Fax

Practice location:
  • Phone: 609-265-0700
  • Fax: 609-265-0708
Mailing address:
  • Phone: 609-265-0700
  • Fax: 609-265-0708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberQA00900100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: