Provider Demographics
NPI:1295009355
Name:VIGIL, ELIZABETH R (LMT 5923)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:R
Last Name:VIGIL
Suffix:
Gender:F
Credentials:LMT 5923
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 28834
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87592-8834
Mailing Address - Country:US
Mailing Address - Phone:505-310-9063
Mailing Address - Fax:
Practice Address - Street 1:1225 PARKWAY DR
Practice Address - Street 2:SUITE B
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-7262
Practice Address - Country:US
Practice Address - Phone:505-699-1359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-06
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5923225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist