Provider Demographics
NPI:1699252056
Name:VILCA, PEGGY REGINA (LMT)
Entity type:Individual
Prefix:MRS
First Name:PEGGY
Middle Name:REGINA
Last Name:VILCA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 E PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07095-3503
Mailing Address - Country:US
Mailing Address - Phone:908-370-5235
Mailing Address - Fax:
Practice Address - Street 1:227 SOUTH AVE W
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07090-1486
Practice Address - Country:US
Practice Address - Phone:908-370-5235
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT00729700225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty