Healthcare Provider Details

I. General information

NPI: 1376225615
Provider Name (Legal Business Name): KRISTAL VIGIL PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2023
Last Update Date: 08/04/2023
Certification Date: 08/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5150 SAN FRANCISCO RD NE STE B
ALBUQUERQUE NM
87109-4396
US

IV. Provider business mailing address

7849 TRAMWAY BLVD NE STE A
ALBUQUERQUE NM
87122-2529
US

V. Phone/Fax

Practice location:
  • Phone: 505-821-3831
  • Fax: 505-212-0786
Mailing address:
  • Phone: 505-821-3831
  • Fax: 505-212-0786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT2114
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: