1013038041 NPI number — VICTORIA ORTHOTIC AND PROSTHETIC SERVICES, INC

Table of content: (NPI 1013038041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013038041 NPI number — VICTORIA ORTHOTIC AND PROSTHETIC SERVICES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VICTORIA ORTHOTIC AND PROSTHETIC SERVICES, INC
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:
6
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:
1013038041
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/22/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1121 MORGAN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORPUS CHRISTI
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78404-3242
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
361-882-4991
Provider Business Mailing Address Fax Number:
361-882-4523

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1121 MORGAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORPUS CHRISTI
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78404-3242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-882-4991
Provider Business Practice Location Address Fax Number:
361-882-4523
Provider Enumeration Date:
04/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
YOUNG
Authorized Official First Name:
WILFORD
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
CEO,; C.O.; L.P.O.
Authorized Official Telephone Number:
361-882-4991

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X , with the licence number:  101063 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 086148601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 086148602 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 086148603 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 530911 . This is a "BLUE CROSS BLUE SHIELD TX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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