Provider Demographics
NPI:1194792812
Name:VICTORIA PHYSICAL THERAPY PC
Entity type:Organization
Organization Name:VICTORIA PHYSICAL THERAPY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF VICTORIA P T PC
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:DROST
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:361-578-3513
Mailing Address - Street 1:601 E SAN ANTONIO
Mailing Address - Street 2:SUITE 301 W
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901
Mailing Address - Country:US
Mailing Address - Phone:361-578-3513
Mailing Address - Fax:361-578-4623
Practice Address - Street 1:601 E SAN ANTONIO
Practice Address - Street 2:SUITE 301 W
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901
Practice Address - Country:US
Practice Address - Phone:361-578-3513
Practice Address - Fax:361-578-4623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-01
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX655760000225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00T47YOtherBLUE CROSS BLUE SHIELD
00T47YOtherBLUE CROSS BLUE SHIELD