Healthcare Provider Details

I. General information

NPI: 1730149493
Provider Name (Legal Business Name): DIANA M. VIGIL AU.D.,CCC-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANA CALLISON M.S., CCC-A

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7801 ACADEMY RD NE STE 102
ALBUQUERQUE NM
87109-3379
US

IV. Provider business mailing address

2060 MAIN ST NE STE A
LOS LUNAS NM
87031-6368
US

V. Phone/Fax

Practice location:
  • Phone: 505-796-4575
  • Fax: 505-796-4575
Mailing address:
  • Phone: 505-916-5977
  • Fax: 505-916-5976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number2247
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number2247
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: