Provider Demographics
NPI:1598284861
Name:GREG VIGNA MD CLCP
Entity Type:Organization
Organization Name:GREG VIGNA MD CLCP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:A/R MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:MEYERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-963-3757
Mailing Address - Street 1:512 E GUTIERREZ ST STE C
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93103-5223
Mailing Address - Country:US
Mailing Address - Phone:805-963-3757
Mailing Address - Fax:805-564-3332
Practice Address - Street 1:1303 MABLE AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355
Practice Address - Country:US
Practice Address - Phone:318-548-2649
Practice Address - Fax:805-564-3332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-18
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDC54741208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1376514190Medicaid