Basic Information
| Provider Information | |||||||||
| NPI: | 1003806597 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VIAL | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | ANTHONY | ||||||||
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| Credential: | MS,PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 515 ASH ST | ||||||||
| Address2: | |||||||||
| City: | SUSANVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961303711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5302577711 | ||||||||
| FaxNumber: | 5302572170 | ||||||||
| Practice Location | |||||||||
| Address1: | 1525 E WINDMILL LN STE 202 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891231903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022021280 | ||||||||
| FaxNumber: | 7023618596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2005 | ||||||||
| LastUpdateDate: | 04/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT14879 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 171080100 | 01 | CA | OWCP PROVIDER NUMBER | OTHER |