Basic Information
Provider Information
NPI: 1003806597
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: VIAL
FirstName: ERIC
MiddleName: ANTHONY
NamePrefix:  
NameSuffix:  
Credential: MS,PT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 515 ASH ST
Address2:  
City: SUSANVILLE
State: CA
PostalCode: 961303711
CountryCode: US
TelephoneNumber: 5302577711
FaxNumber: 5302572170
Practice Location
Address1: 515 ASH ST
Address2:  
City: SUSANVILLE
State: CA
PostalCode: 961303711
CountryCode: US
TelephoneNumber: 5302577711
FaxNumber: 5302572170
Other Information
ProviderEnumerationDate: 10/26/2005
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000XPT14879CAY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

ID Information
IDTypeStateIssuerDescription
17108010001CAOWCP PROVIDER NUMBEROTHER


Home