Basic Information
| Provider Information | |||||||||
| NPI: | 1922025659 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VICTORIA PROSTHETICS & ORTHOTICS INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TEXAS ORTHOTICS AND PROSTHETICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 331580 | ||||||||
| Address2: | |||||||||
| City: | CORPUS CHRISTI | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3618887752 | ||||||||
| FaxNumber: | 3618887424 | ||||||||
| Practice Location | |||||||||
| Address1: | 104 TEAKWOOD | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | VICTORIA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615766027 | ||||||||
| FaxNumber: | 3615763612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 08/15/2013 | ||||||||
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| AuthorizedOfficialLastName: | SEARS | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | COO CFOR | ||||||||
| AuthorizedOfficialTelephone: | 3618887752 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 335E00000X | Y | Suppliers | Prosthetic/Orthotic Supplier |
ID Information
| ID | Type | State | Issuer | Description | 010070302 | 05 | TX | MEDICAID |