Healthcare Provider Details

I. General information

NPI: 1104713007
Provider Name (Legal Business Name): JEROME PABLO VIGIL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2025
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5154
US

IV. Provider business mailing address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5154
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax:
Mailing address:
  • Phone: 505-265-1711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License NumberRCP4518
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: