Healthcare Provider Details

I. General information

NPI: 1255293767
Provider Name (Legal Business Name): RICHARD TOM VIMONT CPSW
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2025
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2504 CAMINO ENTRADA
SANTA FE NM
87507-4851
US

IV. Provider business mailing address

2504 CAMINO ENTRADA
SANTA FE NM
87507-4851
US

V. Phone/Fax

Practice location:
  • Phone: 505-471-4985
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number1928
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: