Healthcare Provider Details

I. General information

NPI: 1336560374
Provider Name (Legal Business Name): RICK VIGIL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2013
Last Update Date: 12/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 CALLE DON DIEGO
ESPANOLA NM
87532-3414
US

IV. Provider business mailing address

714 CALLE DON DIEGO
ESPANOLA NM
87532-3414
US

V. Phone/Fax

Practice location:
  • Phone: 505-367-3342
  • Fax:
Mailing address:
  • Phone: 505-367-3342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberM-07895
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: