Healthcare Provider Details

I. General information

NPI: 1821857814
Provider Name (Legal Business Name): JOSEPH GLENN VIGIL LSAA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2024
Last Update Date: 03/14/2024
Certification Date: 03/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 2ND ST SW
ALBUQUERQUE NM
87102-3831
US

IV. Provider business mailing address

12309 CONEJO RD NE
ALBUQUERQUE NM
87123-1517
US

V. Phone/Fax

Practice location:
  • Phone: 505-577-3750
  • Fax:
Mailing address:
  • Phone: 505-785-4737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCTB-2024-0032
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: