Healthcare Provider Details

I. General information

NPI: 1295433779
Provider Name (Legal Business Name): REBECCA SUE VIGNON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2023
Last Update Date: 02/23/2023
Certification Date: 02/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2875 E STATE ST
SALEM OH
44460-9303
US

IV. Provider business mailing address

2875 E STATE ST
SALEM OH
44460-9303
US

V. Phone/Fax

Practice location:
  • Phone: 330-337-9045
  • Fax: 330-337-9052
Mailing address:
  • Phone: 330-337-9045
  • Fax: 330-337-9052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberOP.10979S
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: