MEDICARE: MRS. NICOLE RENEE VIGIL-OLSIN MA, CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SP 11518	CA

General Provider Information

NPI Number	:	1396982054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NICOLE RENEE VIGIL-OLSIN MA, CCC-SLP

Provider Business Mailing Address
First Line	:	1930 WILSHIRE BLVD STE 904
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90057-3619
Country	:	US
Telephone Number	:	213-353-9019
Fax Number	:	213-353-0336

Provider Business Practice Location Address
First Line	:	1930 WILSHIRE BLVD STE 904
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90057-3619
Country	:	US
Telephone Number	:	213-353-9019
Fax Number	:	213-353-0336

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/15/2009
Last Update Date	:	01/15/2009

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