=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003053398
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARLOS R. VIGIL, D.O. (A PROFESSIONAL CORPORATION)
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2009
-----------------------------------------------------
Last Update Date | 01/08/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7974 HAVEN AVE SUITE 210
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-3052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-941-0661
-----------------------------------------------------
Fax | 909-948-5577
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7974 HAVEN AVE SUITE 210
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-3052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-941-0661
-----------------------------------------------------
Fax | 909-948-5577
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | SUSAN VIGIL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-941-0661
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 20A7446
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------