Healthcare Provider Details

I. General information

NPI: 1235471558
Provider Name (Legal Business Name): AMBER N. VIGIL LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2013
Last Update Date: 07/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

01 SAGEBRUSH RD.
ISLETA NM
87022
US

IV. Provider business mailing address

PO BOX 640
ISLETA NM
87022-0640
US

V. Phone/Fax

Practice location:
  • Phone: 505-869-3200
  • Fax: 505-869-4881
Mailing address:
  • Phone: 505-869-3200
  • Fax: 505-869-4881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD-0884
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: