1376618025 NPI number — MRS. MARY POWELL VIGIL RDH

Table of content: MRS. MARY POWELL VIGIL RDH (NPI 1376618025)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376618025 NPI number — MRS. MARY POWELL VIGIL RDH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VIGIL
Provider First Name:
MARY
Provider Middle Name:
POWELL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RDH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VIGIL
Provider Other First Name:
MARY
Provider Other Middle Name:
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
RDH
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1376618025
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
494 HIGHWAY 92
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DELTA
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81416-3441
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-874-3801
Provider Business Mailing Address Fax Number:
970-874-3807

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
494 HIGHWAY 92
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DELTA
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81416-3441
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-874-3801
Provider Business Practice Location Address Fax Number:
970-874-3807
Provider Enumeration Date:
11/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 124Q00000X , with the licence number:  904294 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 49732048 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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