1417062225 NPI number — VICTORIA ORTHOPEDIC & SPORTS MEDICINE CLINIC, LLC

Table of content: DR. GEOFFREY PETER CARLSON O.D. (NPI 1518968213)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417062225 NPI number — VICTORIA ORTHOPEDIC & SPORTS MEDICINE CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VICTORIA ORTHOPEDIC & SPORTS MEDICINE CLINIC, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417062225
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
605 E SAN ANTONIO ST
Provider Second Line Business Mailing Address:
STE 520E
Provider Business Mailing Address City Name:
VICTORIA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77901-6040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
361-576-0633
Provider Business Mailing Address Fax Number:
367-576-0639

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
605 E SAN ANTONIO ST
Provider Second Line Business Practice Location Address:
STE 520E
Provider Business Practice Location Address City Name:
VICTORIA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77901-6040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-576-0633
Provider Business Practice Location Address Fax Number:
367-576-0639
Provider Enumeration Date:
08/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SPEED
Authorized Official First Name:
BELNDA
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
361-576-0633

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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