Basic Information
| Provider Information | |||||||||
| NPI: | 1194238758 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLORES | ||||||||
| FirstName: | VICTOR | ||||||||
| MiddleName: | MAGALLANES | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MAGALLANES-FLORES | ||||||||
| OtherFirstName: | VICTOR | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 124 CORNELL DR SE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871063509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058503168 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1709 MOON ST NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871123935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052710329 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2017 | ||||||||
| LastUpdateDate: | 11/06/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | NM | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.