Healthcare Provider Details

I. General information

NPI: 1821502469
Provider Name (Legal Business Name): FAUSTIN CHAD VIGIL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2017
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2880 S MAIN ST STE 108
SOUTH SALT LAKE UT
84115-6000
US

IV. Provider business mailing address

9681 S CINDY CT
SOUTH JORDAN UT
84009-1540
US

V. Phone/Fax

Practice location:
  • Phone: 801-810-7611
  • Fax: 801-606-7062
Mailing address:
  • Phone: 801-810-7611
  • Fax: 801-606-7062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10593194-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: